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FRACTURES 


7108 

FRACTURES 


BEING   A   MONOGRAPH   ON 

"GUN  SHOT  FRACTURES  OF  THE  EXTREMITIES" 


BY 


LIEUT.  COLONEL  JOSEPH  A.  BLAKE,  M.C.U.S  A. 

CHIEF  SURGEON  AMERICAN  MILITARY  HOSPITAL  NO.  2,  A.  E.  F. 


WITH  FORTY  ILLUSTRATIONS 


D.  APPLETON  AND  COMPANY 

NEW  YORK  LONDON 

1919 


CoPYRIGnT,  1919,  BY 

D.  APPLETON  AND  COMPANY 


Printed  in  the  Ignited  .States  of  America 


Biomedieal 
Likni7 

PREFACE 

This  little  manual  is  the  outcome  of  a  request  made  to 
me  by  the  late  Dr.  Lewis  A.  Stimson  to  write  a  chapter 
on  fractures  for  a  book  he  was  compiling  for  the  Council 
of  National  Defence  but  which  did  not  materialise  be- 
cause of  his  sudden  death. 

In  it  I  have  attempted  to  put  in  as  concise  a  form  as 
possible  the  conclusions  formed  as  a  result  of  my  ex- 
perience and  observation  since  the  beginning  of  the  war 
in  hospitals  largely  devoted  to  the  treatment  of  fraC' 
tures,  with  the  hope  that  the  manual  may  be  of  some  aid 
to  members  of  the  Medical  Corps  who  have  not  had 
equal  opportunities  in  war  surgery,  and  that  it  may  help 
to  alleviate  the  sufferings  of  our  soldiers  and  diminish 
the  number  of  cripples  who  will  become  a  charge  upon 
our  country.  Perhaps,  also,  suggestions  arising  from 
it  may  lead  to  the  realisation  of  further  progress  and 
thus  assist  our  surgeons  to  continue  the  advance  so  bril- 
liantly begun  by  our  French  and  British  colleagues. 

Joseph  A.  Blake. 


624090 


CONTENTS 

CHAPTER  PAGE 

I. — Mechanism    and    Varieties    of    Gun-shot    Frac- 

TURES 3 

II. — Repair  of  Fractures 12 

III. — Transport  and  Operative  Treatment  of  Frac- 
tures in  General 20 

IV. — Mechanical  Treatment 35 

V. — Diaphyseal  Fractures 51 

VI. — Fractures  and  Wounds  of  Joints 109 


vu 


LIST  OF  ILLUSTRATIONS 

FIGURE  PAGE 

1.  Extensive  wounds  of  tibia  and  fibula  by  rifle  ball  with- 

out complete  fracture 4 

2.  Fracture  of  humerus  by  ball.      Large  and  small  frag- 

ments      5 

3.  Fracture    of    femur    by    shell.        Large    fragments. 

Faulty  position  due  to  lack  of  abduction  of  the 
limb 6 

4.  Extensive  comminuted  fracture  of  femur  by  rifle  ball. 

Illustrating  the  flexion,  abduction  and  rotation  out- 
Avard  of  upper  fragments  observed  in  high  diaphyseal 
fractures  of  the  femur 7 

5.  Double   fracture   of  humerus   by    shell,   suggesting   a 

combined  direct  and  indirect  violence      ....      10 

6.  Fracture  of  tibia  and  fibula.     Infected.     Union  with 

exuberant  callus  and  osteophytes  after  treatment 
without  traction  in  a  bridged  plaster  splint      .       .      13 

7.  Fracture    of    tibia    and    fibula.       Partial    resection. 

Large  callus  with  opening  caused  by  persistent  use 

of  through  and  through  drainage  tube      .       .       .       .      14 

8.  Production  of  exuberant  irregular   callus   about   the 

necrosed  extremity  of  fragment  in  compound  frac- 
ture of  the  femur 17 

9.  Cutting   periosteum   elevator   of   Oilier      .       .       .       .25 

10.  Suspension  frame  for  fractures      .       .       .       .       .       .38 

11.  Detail  of  trolley  bar  for  suspending  the  lower  limb      .      40 

12.  (A)   Thomas    traction    arm    splint.      (B)    Murray's 

modification  of  the  Thomas  traction  arm  splint      .      52 

13.  The  Jones  traction  humerus  splint 53 

ix 


X  LIST  OF  ILLUSTRATIONS 

FIGURE  PAGE 

14.  The  Thomas  traction  arm  splint  used  as  an  ambula- 

tory splint        .  54 

15.  The  Thomas  traction  arm  splint  used  for  bed  treat- 

ment of  fracture  of  the  humerus 55 

16.  Principles  of  suspension  and  traction  for  fractures  of 

the  humerus 56,  57 

17.  Method  of  suspension  for  fracture  of  the  humerus  or 

elbow 58 

18.  A  simple  method  of  producing  traction  and  at  the 

same  time  regulating  abduction    .       .       .       .     •.       .59 

19.  Position  of  extreme  abduction  and  external  rotation 

necessary  in  the  treatment  of  some  fractures  at  the 
surgical  neck  of  the  humerus 62 

20.  Method  of  using  bent  Thomas  traction  arm  splint  for 

treating  fractures  of  the  radius  and  ulna      ...      67 

21.  Suspension  cradle  for  fractures  of  the  radius  and  ulna, 

and  methods  of  installing  traction  and  counter-trac- 
tion         .69 

22.  Van  de  Veld's  splint  for  fractures  of  the  forearm   .      .      70 

23.  Sinclair's  splint  for  fractures  of  the  forearm    ...      71 

24.  Thomas   traction  leg   splint 73 

25.  (A)   Half- ring  modification  of  the  Thomas  traction 

leg  splint.      (B)   Hodgen's  leg  splint.      (C)   Frame 
used  for  suspension  of  fracture  of  the  forearm    .       .      75 

26.  Method  of  attaching  end  of  splint  to  stretcher  sus- 

pension         76 

27.  Method  of  applying  the  Thomas  traction  leg  splint      .      77 

28.  Method  of  treating  high  fractures  of  the  femur  with 

the  Hodgen's  splint  and  traction  by  the  Codavilla 
(Steimann)  pin  or  Besley  tongs 83 

29.  Method  of  treating  high  fractures  of  the  femur  with 

the  half-ring  Thomas  splint 85 

30.  Method  of  suspension  for  fractures  of  both  femora    .      87 


LIST  OF  ILLUSTRATIONS       ,  xi 

FIGURE  PAGE 

31.  Four  methods  of  installing  traction  for  fracture  of  the 

leg 88 

32.  Ransohoif  tongs 89 

33.  Hennequin's   method   in    conjunction   with   Hodgen's 

splint  in  the  treatment  of  fracture  of  the  femur      ,      91 

34.  Delbet's  apparatus  for  ambulatory  treatment  of  frac- 

tures of  the  femur 96 

35.  Method  of  treating  fractures  of  the  tibia  and  fibula  by 

suspension  and  traction 105 

36.  Delbet's  ambulatory  splint  for  fracture  of  the  tibia 

and  fibula 106 

37.  Method  of  cutting  strips  of  crinoline  for  making  the 

plaster   bands   for   Delbet's    ambulatory   splint   for 
fracture  of  the  tibia  and  fibula 107 

38.  Method  of  treating  infected  wounds  of  the  elbow  joint 

by  suspension .    120 

39.  Molded  plaster  splint  for  immobilisation  of  the  wrist.    124 

40.  Method  of  cutting  thicknesses  of   crinoline  to  make 

molded  plaster  splint  for  wrist 125 


SECTION  I 
GENERAL 


GUN-SHOT  FRACTURES 

OF  THE  EXTREMITIES 


CHAPTER    I 


MECHANISM  AND  VARIETIES  OF  GUN- 
SHOT FRACTURES 

Definition: 

A  fracture  is  a  solution  of  the  continuity  of  a  bone. 
Fractures  are  divided  into  two  groups :  fractures  of  the 
diaphyses  and  fractures  of  the  epiphyses.  In  diaphyseal 
fractures  the  false  point  of  motion  is  more  evident  than 
in  epiphyseal  fractures;  there  is  a  tendency  to  over- 
riding and  shortening,  which  is  most  marked  in  the  case 
of  fractures  of  single  bones,  such  as  the  humerus  and 
femur.  In  epiphyseal  fractures  the  articulations  are 
frequently  involved.  Because  of  the  difference  in  the 
process  of  repair,  and  in  the  treatment  necessitated,  the 
two  groups  will  be  described  separately. 

Wounds  of  bones: 

A  distinction  should  be  made  between  fractures  and 
wounds  of  bones.  A  bone  may  be  perforated,  or  a  por- 
tion of  it  broken  off  or  removed  by  a  missile,  and  its 
continuity  still  remain  intact  (Fig.  1).  Such  a  condi- 
tion is  more  often  observed  in  an  epiphysis  than  in  a 
diaphysis.  It  frequently  occurs  that  a  missile  penetrates 

3 


4        GUN-SHOT  FRACTURES  OF  EXTREMITIES 

or  even  perforates  an  epiphysis  without  causing  a  true 
fracture;  but  usually,  when  a  diaphysis  is  perforated, 


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Fig.  1. — Extensive  wounds  of 
tibia  and  fibula  by  rifle  ball 
without  complete  fracture. 

any  slight  indirect  violence  is  sufficient  to  break  the 
remaining  bone.  Nevertheless,  shrapnel  balls  have  per- 
forated the  shaft  of  the  humerus  without  producing  a 
fracture. 


MECHANISM  AND  VARIETIES  OF  FRACTURES     5 

As  regards  the  epiphyses,  it  is  often  difficult  to  dif- 
ferentiate between  wounds  and  fractin-es,  but  it  is  better 


Fig.  2. — Fracture  of  humerus  by 
ball.  Large  and  small  frag- 
ments. This  fracture  united  in 
23  days. 

to  confine  the  term  "wound"  to  those  injuries  which  do 
not  produce  solution  of  continuity  between  important 
parts  of  the  bone.  Wounds  of  the  epiphyses  frequently 
occur  without  implication  of  the  joints. 


6        GUN-SHOT  FRACTURES  OF  EXTREMITIES 

Varieties  of  fractures: 

All  varieties  of  fractures  are  met  with  in  war.    Simple 
fractures  occur  as  often  as  in  any  other  violent  occupa- 


FiG.  3. — Fracture  of  femur  by  shell. 
Large  fragments.  Faulty  position, 
due  to  lack  of  abduction  of  the  limb. 


tion,  but  they  are  caused  more  particularly  by  the  explo- 
sion of  mines  and  shells.     The  essentially  war  fracture 


MECHANISM  AND  VARIETIES  OF  FRACTURES     7 


Fig.  4. — Extensive  comminuted  frac- 
ture of  femur  by  rifle  ball.  Small 
fragments.  Bad  position.  Had 
been  treated  with  a  plaster  splint. 
Illustrates  the  flexion,  abduction 
and  rotation  outward  of  upper 
fragments  observed  in  high  dia- 
physeal fractures  of  the  femur. 


8        GUN-SHOT  FRACTURES  OF  EXTREMITIES 

is  produced  by  the  impact  of  relatively  small  missiles 
traveling  at  a  relatively  high  velocity  and  penetrating 
or  perforating  the  body  or  limbs.  Such  a  fracture  is 
always  compound,  and,  unless  made  by  a  rifle  or  shrap- 
nel ball  (which  do  not,  as  a  rule,  entrain  clothing),  is 
a  priori  infected. 

The  effects  produced  by  missiles  upon  bones  are  ex- 
tremely diverse,  and  it  is  idle  to  try  to  classify  them  too 
minutely.  Occasionally  a  bone  is  broken  transversely 
or  obliquely  into  two  fragments,  but  it  is  much  more 
usual  to  find  comminution.  Such  comminution  may  ex- 
tend for  a  short  distance  only,  the  pieces  being  large 
or  small;  or  the  bone  may  be  shattered  for  a  great  part 
of  its  length  (Figs.  2,  3  et  4).  Not  infrequently  the 
fissures  extend  far  enough  to  involve  articulations. 

It  often  happens  that  the  bone  is  broken  up  into  tiny 
particles  to  which  the  velocity  of  the  missile  is  imparted ; 
these  in  turn  tear  their  way  through  the  soft  tissues, 
thus  producing  the  so-called  "explosive"  effect.  It  is 
largely  to  this  destruction  of  the  soft  tissues  that  war 
fractures  owe  their  peculiar  danger  and  their  need  of 
special  treatment.  In  fractures  of  the  thigh,  for  in- 
stance, there  may  be  relatively  small  apertures  of  en- 
trance and  exit  in  the  skin;  yet  when  these  openings 
are  enlarged  the  hand  may  be  introduced  and  freely 
moved  around  in  a  pulp  of  muscle  filled  with  gritty 
fragments  of  bone.  This  effect  is  seldom  seen  in  an 
epiphysis,  however  it  may  be  shattered,  because  of  the 
less  dense  character  of  the  bone. 

Effects  produced  by  different  missiles  upon  the  bones 


MECHANISM  AND  VARIETIES  OF  FRACTURES     9 

cannot  be  classified  arbitrarily.  The  lesions  caused  by 
rifle  balls  depend  in  character  upon  the  velocity  of  the 
ball.  Unless  it  is  distorted  or  tumbling,  as  a  result  of 
hitting  some  other  object  before  wounding — when  it 
acts  like  a  shell  fragment — it  usually  produces  a  split- 
ting fracture,  or,  in  the  case  of  the  epiphyses,  a  simple 
perforation.  Yet  rifle  balls  may  cause  extensive  minute 
comminution.  Fragments  of  shell,  on  account  of  their 
lesser  velocity,  are  more  apt,  when  causing  fractures, 
to  become  lodged  in  the  bone ;  although  they  frequently 
stop  short  at  its  surface  and  produce  fracture  by  im- 
pact instead  of  by  penetration.  As  a  rule,  such  frac- 
tures are  not  comminuted. 

Double  fracture: 

Double  transverse  fractures  of  a  single  bone,  only 
one  of  which  communicates  with  the  wound  (Fig.  5), 
are  not  infrequently  observed.  In  these  cases  there  is 
often  a  history  of  a  fall,  suggesting  a  combined  direct 
and  indirect  violence. 

Fractures  by  impact  and  fractures  by  penetration  or 
perforation: 

As  has  been  pointed  out  by  Leriche,  the  question  as 
to  whether  the  missile  breaks  the  bone  by  impact  simply, 
or  whether  it  enters  or  passes  through  the  medullary 
cavity,  possesses  great  clinical  importance.  In  the  first 
instance  no  infectious  material  is  carried  into  the  bone, 
and  the  wound  may  be  considered  as  a  wound  of  the 
soft  parts  so  far  as  infection  is  concerned ;  in  the  second, 
if  the  missile  penetrates    the  medulla  or  perforates  the 


10      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

bone,  any  foreign  matter  upon  it  is  generally  caught 
between  the  fragments.     Cases  in  which  the  opening 


Fig.  5. — Double  fracture  of 
humerus  by  shell,  sug- 
gesting a  combined  direct 
and  indirect  violence. 


into  the  medulla  is  small  are  particularly  dangerous  in 
that,  on  account  of  retention  of  the  products  of  infec- 
tion, extensive  osteomyelitis  is  apt  to  be  caused.     The 


MECHANISM  AND  VARIETIES  OF  FRACTURES     11 

difference  between  the  treatment  of  fractures  by  impact 
and  fractures  by  penetration  will  be  considered  later. 

Infection: 

Fractures  produced  by  rifle  balls,  if  the  orifices  of 
entrance  and  exit  are  small,  are  considered  as  unin- 
fected; when  caused  by  shrapnel  balls,  judgment  must 
be  used  as  to  whether  to  consider  them  infected  or  not. 
Generally,  when  the  orifices  in  the  skin  are  small  and 
punctate,  they  may  be  taken  to  be  uninfected;  but  if 
proper  conveniences  are  at  hand  for  the  performing  of 
an  aseptic  operation  no  doubtful  case  should  be  allowed 
to  pass. 

All  fractures  produced  by  shell,  bomb  or  grenade 
fragments  must  be  regarded  as  infected.  In  the  great 
majority  of  cases  clothing,  hair,  skin  or  other  foreign 
bodies  are  entrained  by  the  projectile.  This  foreign 
material  is  often  found  entangled  in  the  bone  splinters. 


CHAPTER  II 

REPAIR  OF  FRACTURES 

The  process  of  repair  in  fractures  produced  by  mis- 
siles does  not  differ  in  principle  from  that  observed  in 
the  ordinary  fracture  in  civil  practice;  but  with  the 
former,  on  account  of  extensive  comminution  and  dis- 
placement of  small  fragments,  results  having  a  far- 
reaching  effect  upon  the  ultimate  function  of  the  mem- 
ber may  occur.  Infection  markedly  influences  repair, 
and  it  is  therefore  well  to  consider  the  uninfected  cases 
first. 

In  the  absence  of  infection  there  is  no  death  of  tis- 
sue, at  least  in  mass,  and  new  bone  is  produced  to  a 
varying  extent  by  all  the  osteogenetic  tissue,  whether 
attached  to  periosteum  or  bone  fragments,  or  contained 
within  them.  If  there  is  no  comminution  the  repair  does 
not  differ  from  that  of  a  similar  simple  fracture  caused 
by  indirect  violence,  except  that,  as  the  periosteum  has 
usually  not  been  stripped  from  the  ends  of  the  bones, 
the  repair  takes  place  more  normally  and  more  rapidly. 
In  cases  of  extensive  comminution  (Figs.  2  and  3)  the 
new  bone  forms  around  and  between  all  the  fragments 
as  if  cement  had  been  poured  in  between  them,  and,  as 
the  broken  surfaces  present  a  far  greater  area  than 
those  of  a  non-comminuted  fracture,  the  formation  of 
new  bone  is  much  increased  and  the  site  of  union  cor- 
respondingly enlarged;  the  size  and  irregularity  of  the 
callus  depending  upon  the  separation  and  distribution 


REPAIR  OF  FRACTURES 


13 


of  the  fragments.     Osteophj^tic  processes  often  extend 
into  the  muscles,  interfering  greatly  with  their  function 


Fig.  6. — Fracture  of  tibia  and  fibula,  in- 
fected; united  with  exuberant  callus 
and  osteophytes.  Had  been  treated 
without  traction  in  a  bridged  plaster 
splint. 

(Fig.  6).  Nerves  may  be  surrounded  and  included. 
Pieces  of  bone  entirely  detached  from  the  others  and 
projected  into  muscles  do  not,  however,  produce  new 
bone,  but,  as  has  been  shown  in  cases  of  experimental, 


14      GUN-SHOT  FRACTURES  OF  EXTREMFriES 


Fig.  7. — Fracture  of  tibia  and 
fibula:  partial  resection.  Large 
callus  with  opening  through  it 
caused  by  persistent  use  of 
through  and  through  drainage 
tube. 


REPAIR  OF  FRACTURES  16 

implantation  of  bone  into  tissues  distant  from  bone, 
are  gradually  absorbed.  The  tendency  to  excessive 
bone  production  can  be  controlled  to  a  certain  degree 
by  proper  treatment.  Traction  by  stretching  the  mus- 
cles tends  to  confine  the  fragments  to  normal  limits, 
and  no  drainage  tubes  or  packing  should  be  introduced 
between  them.  Fig.  7  shows  an  opening  produced 
through  a  callus  by  a  large  drainage  tube.  Such  holes 
and  cavities  close  but  slowly,  if  they  close  at  all. 

Union  of  uninfected  comminuted  fractures  usually 
takes  place  very  rapidly.  Fractures  of  the  humerus  are 
not  infrequently  united  in  three  weeks  and  fractures 
of  the  femur  in  from  four  to  five  weeks. 

Infection  not  only  delays  union  as  a  rule,  but  also, 
by  causing  the  death  entirely  or  in  part  of  fragments, 
gives  rise  to  obstinate  sinuses  leading  to  the  dead  frag- 
ments or  sequestra,  which  do  not  close  until  the  dead 
bone  is  removed  and  then  often  very  slowly  on  account 
of  the  irregular  cavities  left  in  the  callus.  Mild  infec- 
tion stimulates  bone  formation  to  a  certain  degree,  and 
the  excessive  growth  of  the  involucrum  about  the  ne- 
crossed  bone,  thereby  caused,  frequently  results  in  the 
production  of  irregular  and  exuberant  callus  which  in- 
terferes greatly  with  the  function  of  muscles  and  joints 
in  proximity  to  them.  Furthermore,  long-continued  in- 
fection kept  up  by  the  presence  of  dead  bone  and  the 
abscesses  caused  by  the  blocking  of  drainage  by  repar- 
ative tissue  leads  to  infiltration  of  the  surrounding  soft 
parts  by  scar  tissue,  and  this,  added,  to  the  incisions 
which  have  to  be  made  to  afford  drainage,  has  most 
deleterious  effects  upon  the  function  of  the  member. 


16      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

Typical  osteomyelitis  is  exceptional  in  comminuted 
fractures  on  account  of  the  free  drainage  afforded  to  the 
medullary  cavity.  Not  infrequently  a  limited  osteo- 
myelitis is  observed  in  transverse  fractures  and  results 
in  the  death  and  separation  of  the  entire  ends  of  the 
fragments.  This  is  particularly  true  of  fractures  in 
which  the  periosteum  is  stripped  from  the  ends  of  the 
fragments,  thus  depriving  them  of  their  nutrition  and 
at  the  same  time  allowing  infection  to  enter.  Destruction 
of  the  medullary  artery  is  a  frequent  cause  of  extensive 
necrosis.  Occasionally  a  missile  engenders  fissures 
which,  on  account  of  the  elasticity  of  the  bone,  close, 
entrapping  foreign  material  and  thus  producing  osteo- 
myelitis. Fissures  that  close,  however,  rarely  cause 
extension  of  infection.  It  is  rather  the  open  fissure, 
along  which  infection  may  extend  but  which  does  not 
afford  sufficient  drainage,  that  gives  rise  to  extensive 
infection  of  the  marrow  cavity.  Such  fissures,  extend- 
ing through  the  epiphyses  into  the  joints,  may  lead  to 
infection  of  the  latter,  necessitating  amputation  in  order 
to  save  life. 

Insufficient  drainage  of  the  medullary  cavity  is  a 
cause  of  grave  spreading  of  infection  resulting  in  ex- 
tensive death  of  bone,  and  this  is  why  typical  osteomye- 
litis is  more  common  in  slight  wounds  and  injuries  of  the 
bones  than  in  severer  ones.  Even  deficient  drainage  of 
the  wounds  of  the  soft  parts  increases  the  infection  and 
therefore  prepares  the  way  for  the  death  of  bone. 

When  necrosis  of  fragments  situated  centrally  to  the 
forming  callus  occurs  (as,  for  instance,  the  ends  of  the 
main  fragments),  a  flask-like  callus  is  apt  to  form  con- 


REPAIR  OF  FRACTURES 


17 


taining  the  sequestra  in  its  cavity.  As  time  goes  on 
this  calkis  is  added  to  peripherally  and  excavated  cen- 
trally, on  account  of  the  absorption  going  on  about  the 


Fig.  8. — Production 
of  exuberant  ir- 
regular callus 
about  the  ne- 
crosed extremity 
of  fragment  i  n 
compound  f  r  a  c  - 
ture  of  the  femur. 
Note  the  absorp- 
tion of  the  interior 
of  the  callus  about 
the  sequestrum. 
(By  the  courtesy 
of  M.  le  Medecin- 
Major  R.  Ler- 
iche). 


sequestra,  and  the  flask  is  thus  increased  (Fig.  8) .  This 
produces  a  very  troublesome  condition,  necessitating 
resection  of  one  side  of  the  flask  to  permit  closure  of 
the  cavity\ 

'Page  32. 


18      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

Repair  in  injuries  of  the  epiphyses  and  in  the  short 
bones  differs  from  that  observed  to  take  place  in  the 
diaphyses.  There  is  no  medullary  cavity,  and  true 
osteomyelitis  does  not  occur.  On  the  other  hand,  in- 
fection leads  to  a  troublesome  osteitis,  characterized  by 
fragmental  death  rather  than  necrosis  en  masse. 

The  peculiarly  obstinate  infection  and  suppuration 
noticed  in  cancellous  bone  can  be  explained  by  the  char- 
acter of  the  lesions  produced  by  projectiles.  Such  tis- 
sue, when  penetrated,  has  a  tendency  to  close  behind 
the  missile,  which  may  either  lodge  or  perforate.  Along 
the  tract  thus  closed  are  scattered  minute  fragments 
of  infectious  material,  and  about  it  is  an  extensive  zone 
of  hemorrhagic  contusion.  Into  this  area  the  infection 
may  extend,  giving  rise  to  scattered  foci  of  necrosis. 
In  continued  infection  the  bony  trabeculse  become  ab- 
sorbed and  the  fatty  tissue  increases,  so  that  the  entire 
epiphysis  becomes  softened.  This  softening  is  fre- 
quently mistaken  by  the  surgeon  for  necrosis,  and  he 
may  do  irreparable  injury  by  curetting  out  tissue  which, 
with  the  subsidence  of  infection  and  the  resumption  of 
function,  would  again  become  firm.  These  cavities  do 
not  fill  with  new  bone,  and  may  have  to  be  levelled  up 
by  the  implantation  of  soft  tissue  such  as  fat. 

Besides  causing  death  of  bone,  injury  to  the  nutrient 
vessels  of  a  bone  has  a  marked  influence  upon  repair, 
especially  in  infected  fractures.  This  is  evidenced  by 
a  rarefaction  of  the  bone  deprived  of  its  nutrition  and 
a  lack  of  new  bone  formation,  and  not  infrequently  by 
non-union.  Bone  grafts  do  not  take  well  in  such 
cases. 


REPAIR  OF  FRACTURES  19 

Non-Union: 

Non-union  rarely  happens  in  comminuted  fractures, 
and  should  not  occur  in  non-comminuted  fractures 
properly  treated.  The  author  has  never  observed  it  in 
comminuted  fractures  in  which  the  fragments  were  not 
removed;  but  it  occurs  frequently  after  improper  re- 
section of  the  fragments. 

Union  almost  invariably  occurs  by  means  of  the  in- 
volucrum,  even  in  the  presence  of  extensive  necrosis  of 
the  ends  of  the  bones,  if  the  fragments  are  kept  in  a 
reasonably  good  position.  If  by  mischance  the  involu- 
crum  should  break,  union  usually  recurs  rapidly;  but 
occasionally,  particularly  in  old  cases  in  which  efforts 
toward  repair  seem  to  have  exhausted  themselves,  defi- 
nite non-union  results.  In  such  cases  the  extremities 
of  the  fragments  are  found  to  be  rounded  and  the 
medullary  cavity  to  be  plugged  by  eburnated  bone. 
In  such  cases  union  will  never  take  place  until  the  tnds 
of  the  fragments  are  resected  or  the  continuity  of  the 
medulla  re-establishd  by  an  inlay  graft. 


CHAPTER  III 

TRANSPORT  AND  OPERATIVE  TREAT- 
MENT OF  FRACTURES  IN  GENERAL 

TRANSPORT 

The  first  treatment  to  be  applied  to  a  gun-shot  frac- 
ture is  the  cutting  away  of  the  clothing,  the  painting  of 
the  wound  and  skin  about  it  with  iodine  and  the  appli- 
cation of  the  first  aid  dressing.  Then  comes  the  most 
important  (and  often  greatly  mismanaged)  part, 
namely,  the  transportation  of  the  wounded  man  to  the 
dressing  station  and  thence  on  toward  the  rear. 

The  question  of  transportation,  so  far  as  distance  and 
stages  are  concerned,  depends  largely  upon  the  exigen- 
cies of  the  military  situation;  but  it  has  been  amply 
proved  during  this  war  that  the  less  the  transportation 
the  better  for  a  fracture. 

In  every  case  traction  should  be  applied  to  the  limbs 
in  order  to  avoid  laceration  of  muscles,  vessels  and 
nerves  by  the  sharp  fragments,  and  to  prevent  over-rid- 
ing and  stripping  of  the  periosteum.  If  traction  be 
efficiently  applied  harmful  angulation  at  the  site  of 
fracture  cannot  occur. 

For  the  treatment  of  fractures  during  transport 
splints  and  apparatus  must  be  light  and  non-cumber- 
some, for  otherwise  they  cannot  be  taken  to  the  advanced 
posts.  Moreover,  they  should  be  of  such  a  nature  that 
they  may  be  easily  and  quickly  applied  and  not  inter- 
fere with  the  dressing  of  wounds.     They  should  be  de- 

20 


FRACTURES  IN  GENERAL  21 

signed  to  produce  reduction  and  maintain  alignment 
of  the  bone  fragments;  treatment  may  then  be  con- 
tinued with  the  same  apparatus.  It  is  difficult,  how- 
ever, to  find  an  apparatus  combining  all  these  desid- 
erata, and  usually  another  is  substituted  at  the  hospital 
in  which  the  treatment  is  carried  out.  The  various 
splints  will  be  described  under  the  headings  for  each 
fracture. 


OPERATIVE  TREATMENT 

Primary  operations: 

No  operation  should  be  performed  until  the  wounded 
reach  a  place  where  formal  aseptic  surgical  treatment 
can  be  given — except  in  case  of  hemorrhage,  for  which 
neither  a  tourniquet  nor  a  tampon  should  be  used,  but 
the  bleeding  point  caught  by  a  forceps.  The  tourniquet 
is  provocative  of  gas  gangrene  and  the  tampon  of  in- 
fection. When  either  has  to  be  used  the  patient  should 
be  a  rush  case  for  operation. 

Every  fracture  should  be  operated  with  the  exception 
of  those  caused  by  a  bullet  in  which  both  wounds  are 
punctate.  The  operation  should  be  performed  at  the 
earliest  possible  moment;  it  is  not  a  question  of  days 
but  of  hours,  even  minutes.  Gas  gangrene  has  been 
known  to  set  in  three  hours  after  injury,  and  the  earlier 
the  operation  the  surer  the  prevention  of  this,  tetanus 
and  the  ordinary  suppurating  infections. 

The  operative  technique  is  extremely  important,  for 
upon  the  success  of  the  primary  operation  in  removing 
the  causes  of  infection  depend  the  entire  aftercourse  of 


22      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

the  wound  and  perhaps  the  Hfe  of  the  patient.  With  the 
exception  of  special  procedures  in  the  case  of  wounds 
and  fractures  of  certain  joints  which  will  be  treated 
later,  the  operative  treatment  resolves  itself  into  two 
categories :  that  of  the  soft  parts  and  that  of  the  bones. 

In  general,  wounds  of  the  soft  parts  complicating 
fractures  are  treated  in  the  same  manner  as  those  of  the 
soft  parts  alone.  The  region  is  prepared  by  dry  shav- 
ing and  cleansing  with  ether  followed  by  a  3-5  per 
cent,  solution  of  iodine  in  alcohol.  After  excision  of  the 
edges  the  wound  is  enlarged  superficially  so  that  the 
whole  of  the  deeper  recesses  are  laid  widely  open  to 
view.  The  deep  surfaces  are  then  pared  with  scissors 
or  scalpel  until  healthy,  unlacerated  tissues  are  reached ; 
the  proper  depth  is  determined  by  their  color,  and 
especially  by  their  contractile  response.  Some  surgeons 
employ  a  fixative  stain,  consisting  of  5  per  cent,  methyl 
blue  and  20  per  cent,  formalin  (i.  e.,  half  the  commer- 
cial 40  per  cent.,  a  weaker  solution  not  being  sufficient) , 
to  color  the  devitalized  parts,  but  equally  good  results 
are  reported  by  those  who  use  nothing.  If  the  oper- 
ation is  methodically  and  correctly  performed  it  is  ob- 
vious that  when  the  whole  of  the  superficies  of  the 
wound  surfaces  is  removed  all  foreign  materials  are 
removed  as  well,  so  that  theoretically  there  is  no  need  of 
X-rays  to  determine  the  presence  of  missiles ;  but  prac- 
tically, an  accurate  localization  by  the  X-ray  gives  val- 
uable information  in  helping  to  determine  the  course 
of  the  projectile  and  the  approach,  especially  if  counter 
incisions  have  to  be  made. 

Wounds  treated  in  this  way  may  be  closed  by  pri- 


FRACTURES  IN  GENERAL  23 

mary,  delayed  primary,  or  secondary  suture.  The  term 
primary  suture  is  applied  to  the  immediate  closure  of 
wounds.  When  suture  is  performed  after  a  delay  of 
two  or  three  days  because  of  doubt  as  to  the  removal  of 
contamination  or  because  of  the  evacuation  of  the 
patient  (i.  e.,  removal  from  observation),  the  term  de- 
layed primary  suture  is  employed.  If  the  operation  to 
close  the  wound  has  to  be  postponed,  on  account  of  in- 
fection, until  the  formation  of  granulations,  the  term 
secondary  suture  is  used.  In  the  latter  case  a  second 
excision  of  the  wound,  entailing  a  further  sacrifice  of 
normal  tissue,  is  necessary ;  if  this  is  not  done  the  opera- 
tion seldom  succeeds,  or  results  in  the  production  of  an 
inordinate  amount  of  cicatricial  tissue.  Primary  or  de- 
layed primary  suture  is  therefore  obviously  preferable 
to  secondary  suture,  and  should  always  be  done  if  pos- 
sible. 

Uncomplicated  wounds  of  the  soft  parts  may  be  suc- 
cessfully closed  by  primary  or  by  delayed  primary 
suture  in  98  to  99  per  cent,  of  cases;  the  structures  in- 
volved are,  as  a  rule,  of  minor  importance,  and  risks 
may  be  taken  that  would  be  unwarrantable  were  the 
wounds  complicated  by  fractures.  Nevertheless,  most 
fractures  may  also  be  closed  in  this  way  if  certain  points 
in  the  operative  technique  are  carefully  observed;  in- 
deed, in  many  cases,  as  will  be  shown,  they  may  be 
sutured  primarily  with  as  much  impunity  as  wounds  of 
soft  parts  alone.  It  is,  as  a  general  principle,  however, 
more  prudent  to  practise  delayed  primary  suture  when 
a  fracture  is  present,  on  account  of  the  difficulty  of  re- 
moving foreign  materials  from  among  the  bone  frag- 


24      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

ments.  Herein  lies  the  importance  of  distinguishing 
between  fractures  by  impact  and  fractures  by  penetra- 
tion. 

In  the  former  case  the  projectile  does  not  enter  the 
medullary  canal,  and  the  wound  may  be  sutured  as 
though  it  were  an  uncomplicated  wound  of  the  soft 
parts.  The  stitches  should  be  interrupted  and  spaced 
sufficiently  to  permit  a  certain  amount  of  drainage  and 
yet  accurately  approximate  the  tissues.  A  few  strands 
of  silkworm  gut  are  inserted  to  serve  the  double  purpose 
of  draining  the  wound  and  providing  a  tell-tale  as  to 
the  bacteriological  flora  it  may  contain;  they  are  re- 
moved at  the  end  of  the  second  or  third  day  and  cul- 
tured to  determine  v/hether  the  wound  may  remain 
closed  or  should  be  re-opened. 

If  the  missile  has  penetrated  or  perforated  the  bone, 
however,  the  medullary  canal  must  be  considered  to  be 
contaminated,  and  must  be  laid  open  and  explored.  To 
do  this  it  is  nearly  always  necessary  to  remove  some  of 
the  fragments.  Absolutely  detached  fragments  should 
always  be  removed,  since  they  have  become  foreign 
bodies  and  will  surely  necrose  should  infection  super- 
vene. Unhappily  their  removal  seldom  affords  suffi- 
cient exposure  of  the  medulla,  and  therefore  fragments 
still  attached  to  their  periosteum  must  also  generally  be 
cut  away.  The  greatest  care  must  be  exercised  in  excis- 
ing them,  and  only  enough  and  no  more  should  be  re- 
moved. Care  should  be  taken  to  leave  at  least  one  or 
more,  if  possible,  to  preserve  the  continuity  of  the  shaft. 
In  other  words,  if  a  resection  is  done  it  should  be  lateral 
and  not  transverse  in  character.    When  a  piece  has  to 


FRACTURES  IN  GENERAL 


25 


be  removed  it  must  never  be  torn  or  pried  away;  it 
must  be  cut  out,  leaving  its  outer  layer  adherent  to  the 
periosteum.  This  can  only  be  done  by  one  instrument, 
namely,  the  cutting  periosteum  elevator  of  Oilier  (Fig. 
9) .     The  edge  of  this  rugine  must  be  kept  as  sharp  as  a 


Fig.    9. — Cutting   Periosteum 
Elevator  of  Oilier. 

razor,  and  several  may  have  to  be  used  during  an  opera- 
tion; a  number  of  them,  of  various  sizes,  should  be  at 
hand.  The  fragment  to  be  separated  must  be  held 
firmly  in  a  bone  forceps  while  its  outer  layer  is  sliced 
off  by  lateral  movements  of  the  rugine.  The  medulla 
having  been  sufficiently  exposed,  all  loose  fragments 
and  pulpified  medulla  should  be  removed,  as  the  latter 
is  apt  to  be  filled  with  particles  of  clothing. 

In  the  case  of  fractures  in  which  the  missile  has  per- 
forated the  bone,  comminution  is  frequently  more 
marked  at  the  side  of  the  bone  opposite  to  the  wound 
of  entrance  and  the  soft  parts  there  are  more  likely  to 
be  filled  with  contaminated  bone  fragments  and  there- 
fore to  need  more  careful  treatment  than  those  on  the 


26      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

side  of  entrance.  Consequently,  in  such  a  case  it  is 
wise  to  approach  the  medullary  cavity  from  both  sides 
of  the  limb. 

For  fractures  by  penetration  great  judgment  must 
be  exercised  in  practising  primary  suture,  the  nature  of 
the  missile,  the  time  elapsed  since  wounding,  the  char- 
acter of  the  wound  and  its  situation,  as  well  as  whether 
the  patient  is  to  be  kept  under  observation  or  evacuated, 
must  be  taken  into  account.  It  is  wiser  for  an  inex- 
perienced surgeon  to  practise  delayed  primary  suture. 
Certain  fractures,  such  as  those  of  the  femur,  which  are 
surrounded  by  thick  muscles  in  which  the  anaerobic  bac- 
teria are  apt  to  proliferate,  should  not  be  closed  pri- 
marily except  under  exceptionally  favorable  conditions. 
If  infection  supervenes  in  a  closed  wound  it  is  much 
more  violent  in  character  than  in  an  open  one,  and  re- 
sults in  a  far  greater  setback  to  convalescence. 

If  there  is  grave  doubt  as  to  whether  the  wounds  are 
infected  (as,  for  example,  in  the  case  of  delay  before 
operation  exceeding  eight  hours — the  period  during 
which  bacteria  remain  latent)  it  is  better  not  only  to 
leave  the  wounds  widely  open  but  also  to  use  a  complete 
Carrel  installation  so  as  to  remove  the  wound  secretions 
as  completely  as  possible  during  the  first  few  days  fol- 
lowing the  operation. 

A  fracture  which  is  transported  after  operation  is 
more  hkely  to  become  infected  than  one  retained  in  the 
service  of  the  operator,  and,  consequently,  as  many 
fractures  as  possible  should  be  kept  in  the  hospital 
where  they  have  been  operated.  If  they  must  be  evac- 
uated, delayed  primary  suture  may  be  done  at  the  hos- 


FRACTURES  IN  GENERAL  27 

pital  in  which  the  patient  is  ultimately  retained.  It  is 
extremely  important  that  the  series  of  hospitals  through 
which  fractures  pass  should  be  in  close  relation  with  one 
another  so  that  the  results  of  operations  may  be  closely 
followed. 

Operations  in  infected  cases: 

In  obviously  infected  cases  successful  primary  suture 
cannot  be  hoped  for.  Tissues  which  have  already  devel- 
oped protection  should  not  be  excised,  but  all  dead  and 
foreign  material  must  be  removed  and  free  and  efficient 
drainage  afforded.  The  incision  should  be  free  enough 
to  enable  inspection  of  the  entire  wound  by  sight,  but 
the  operation  must  be  gently  done  and  no  indiscriminate 
rooting  with  the  fingers  is  permissible. 

In  cases  of  gas  infection  (B.  Welchii),  the  incision 
should  be  very  free  and  all  dead  muscle  removed.  In 
exceptional  caseis  the  entire  muscle  may  have  to  be  ex- 
cised. In  any  case,  the  incisions  should  reach  into  freely 
bleeding  muscle.  It  is  to  be  remembered  that  the  gas 
infection  extends  along  a  muscle  and  is  often  limited  by 
the  muscle  sheaths.  Incisions  should,  therefore,  be  lon- 
gitudinal, in  the  axis  of  the  muscle,  and  never  trans- 
verse. 

In  infected  fractures  it  is  usually  unwise  to  resect  or 
remove  any  attached  fragments ;  it  is  better  to  wait  until 
the  dead  or  dying  portions  of  bone  are  sequestrated.    * 

All  such  wounds  should  be  left  freely  open,  with 
gauze  laid  lightly  in  them.  Paraffined  gauze  does  not 
stick  and  may  be  used,  but  ordinary  gauze  drains  better 
and  should  not  be  removed  until  it  is  loosened.     It  is 


28      GUX-SHOT  FRACTURES  OF  EXTREMITIES 

sufficient  to  keep  the  exposed  parts  of  the  wound  well 
cleansed  with  soap  and  water,  and  hydrogen  peroxide 
if  obtainable,  afterward  washing  with  alcohol  or  ether. 
The  use  of  drainage  tubes  is  bad  practice,  for  they  only 
drain  locally  and  allow  the  surface  of  the  remainder  of 
the  wound  to  adhere  and  form  pockets.  If  drainage 
is  indicated  it  is  advisable  to  employ  the  Carrel  method 
of  using  many  small  tubes  and  intermittent  irrigations. 
It  is  obvious  that  an  infected  fracture  must  not  be  secon- 
darily sutured  until  all  dead  bone  is  eliminated. 

Resection: 

Typical  resection  (i.  e.,  removal  of  all  the  fragments) 
of  diaphyseal  fractures  is,  in  general,  to  be  condemned. 
Good  results  have  been  obtained  by  surgeons  skilled  in 
the  technique  of  resection,  but  it  is  not  a  procedure  to  be 
recommended.  The  resection  should  be  confined  to  the 
removal  of  only  sufficient  bone  to  expose  the  medullary 
canal  {vide  supra). 

On  the  other  hand,  certain  fractures  of  the  joints 
should  be  resected,  so  that  every  surgeon  must  familiar- 
ize himself  with  the  rules  governing  the  operation  or  his 
results  will  be  failures.  The  greatest  care  must  be 
taken  to  preserve  the  periosteum  as  a  continuous  sheet 
in  so  far  as  possible,  or  the  consequences  will  be  disap- 
pointing. The  elevator  or  rugine  of  Oilier  (Fig.  9) 
should  be  used  for  the  purpose.  The  periosteum  is  sep- 
arated but  a  thin  shaving  of  bone  is  left  adhering  so 
that  the  osteogenetic  layer  is  well  conserved.  In  using 
the  instrument  the  hand  must  be  controlled  so  as  to 
avoid  slips  and  tearing  of  the  periosteum.    The  great- 


FRACTURES  IN  GENERAL  29 

est  care  should  be  exercised  in  removing  the  muscular 
attachments. 

As  a  rule,  the  resection  should  not  be  unilateral ;  that 
is,  the  cartilage,  at  least,  should  be  removed  from  the 
other  bones  forming  the  articulation  with  the  exception 
sometimes  of  the  glenoid  cartilage  in  the  shoulder.  The 
classical  incisions  should  be  made  unless  the  wound 
affords  abundant  access. 

The  wound  is  lightly  packed  with  gauze;  some  sur- 
geons prefer  iodoform  gauze,  although  it  is  not  indis- 
pensable, especially  in  clean  cases.  The  packing  is  ar- 
ranged so  as  to  keep  the  periosteal  tube  from  collapsing, 
and  is  used  for  two  or  three  weeks,  being  changed  as  in- 
frequently as  possible.  Tubes  have  to  be  used  in  some 
resections — such  as  resection  of  the  hip  by  the  anterior 
method,  in  which  dependent  drainage  through  a  pos- 
terior opening  is  necessary. 

In  mfected  cases  the  aim  is  to  keep  the  ends  of  the 
bones  separated  (even  in  the  knee  when  ankylosis  is 
desired),  until  the  infection  has  subsided.  Too  much 
stress  cannot  be  laid  on  removing  all  the  cartilage  in 
infected  cases,  because  it  prevents  repair  and  prolongs 
suppuration.  The  after-care  is  most  important  and  will 
be  considered  with  the  treatment  of  fractures  of  special 
joints.  In  general,  where  a  return  of  function  is  sought 
for,  very  early  motion  should  be  instituted,  particularly 
active  motion  by  the  patient,  in  order  to  maintain 
the  function  of  the  muscles,  and,  by  their  contraction, 
to  pull  out  and  mold  the  new  bone  to  its  proper 
shape. 

The  indications  for  and  technique  of  resections  of  the 


30      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

various  joints  will  be  considered  under  the  heading  of 
each. 

Internal  fixation: 

Systematic  plating,  banding  and  wiring  of  compound 
fractures  of  war  have  had  an  extensive  trial  and  are 
almost  universally  condemned.  In  exceptional  cases 
this  procedure  may  be  practised  when  a  fracture  can- 
not be  retained  in  reduction  by  other  means,  but  such 
cases  are  rare.  It  is  often  a  temptation  to  band  or  wire 
long  splintering  fractures,  but  equally  good  results  can 
be  obtained  otherwise  without  the  risks  of  the  operation. 
Internal  fixation  of  an  infected  fracture  is,  as  a  rule, 
bad  surgery. 

Operations  for  sequestra  and  hone  sinuses: 

Nearly  every  case  of  infected  war  fracture  unites 
with  sequestra  in  the  callus.  The  sinuses  resulting 
therefrom  are  difficult  to  close  and  often  keep  a  soldier, 
who  is  otherwise  perfectly  well,  from  active  duty  for 
months  and  even  years.  They  will  not  definitely  heal 
until  the  necrosed  bone  is  removed,  and  this  should 
therefore  be  done  at  the  earliest  possible  moment,  not 
only  to  enable  the  sinus  to  close  but  to  avoid  osteitis 
and  excessive  formation  of  callus. 

Judgment  must  be  exercised  as  to  when  to  operate. 
If  the  operation  is  performed  before  the  dead  bone  has 
become  separated  it  will  be  a  failure,  because  the  trau- 
matism provoked  in  removing  the  necrotic  portion  leads 
to  further  necrosis.  There  is  also  great  danger  of  re- 
fracturing  weak  unions. 


FRACTURES  IN  GENERAL  31 

The  moment  to  operate  is  when  the  dead  portions 
have  been  detached  from  the  hving,  at  which  time  they 
can  be  picked  out  of  the  sinus  with  the  least  traumatism. 
Usually  this  occurs  in  six  weeks,  but  the  time  is  influ- 
enced by  the  amount  of  blood  supply  to  the  parts.  In 
weak  unions  it  may  often  be  wise  to  wait  for  the  growth 
of  more  callus,  but  it  must  be  remembered  that  an  area 
of  absorption  is  being  created  about  the  sequestrum  and 
the  operation  should  not  be  postponed  until  disagree- 
able cavities  are  formed. 

The  best  way  of  determining  the  presence  and  loca- 
tion of  sequestra,  if  they  cannot  be  felt  by  the  probe,  is 
by  X-rays.  Stereoscopic  plates  should  be  taken  by 
which  the  sequestra  can  be  localized  standing  out  by 
themselves  surrounded  by  a  clear  interval  between  them 
and  the  less  dense  callus.  In  this  way  their  exact  num- 
ber and  location  can  be  determined  and  everyone  sub- 
sequently accounted  for  at  operation.  The  trouble  and 
expense  of  stereoscopic  plates  are  far  less  than  those 
of  several  operations  and  the  cost  of  months  of  treat- 
ment thereby  entailed. 

Operations  for  sequestra  possess  none  of  the  excite- 
ment, of  abdominal  surgery  but  are  even  more  difficult 
and  require  the  most  painstaking  care.  As  a  rule  the 
sinus  and  scar  are  excised  and  the  opening  thus  made 
used  as  the  approach — unless  the  sequestrum  has  been 
located  on  the  other  side  of  the  bone,  when  an  incision 
over  it  should  be  made.  The  dissection  is  carried  out 
along  the  sinus  and  if  the  necrotic  bone  is  within  the 
callus  the  periosteum  should  be  carefully  lifted.  The 
callus  should  be  interfered  with  as  little  as  possible.    By 


32      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

efficient  sponging  the  dead  white  sequestrum  can  be 
seen  and  removed.  Others,  if  present,  should  be  sought 
for  in  the  same  way;  the  stereoscopic  plates  being  on 
view  so  that  their  relations  with  one  another  may  be  com- 
pared.   Blind  curettage  of  a  bone  sinus  is  bad  practice. 

The  aniline  antiseptic  dyes — methyl  blue,  gentian 
violet,  flavine  or  brilliant  green — may  be  used  to  stain 
the  sinuses  and  are  of  help,  but  they  are  not  so  reliable 
as  stereoscopic  X-ray  plates.  It  is  difficult  to  obtain 
penetration  of  the  stain  throughout  the  sinuses. 

After  removal  of  the  sequestra,  in  the  presence  of  a 
reasonably  clean  field  the  ends  of  the  incision  may  be 
approximated,  and  drainage  may  be  dispensed  with  un- 
less evidently  needed,  when  hght  gauze  packing  should 
be  employed. 

Sometimes  when  the  operation  to  remove  sequestra  is 
deferred  for  too  long  a  period,  particularly  when  large 
portions  of  the  main  fragments  necrose,  large  cavities 
are  formed  more  or  less  completely  surrounded  by  an 
irregular  callus.  Such  cavities,  unless  operated  on  be- 
fore the  medullary  cavity  of  the  main  fragment  is 
plugged  by  new  bone  (thus  stopping  all  regeneration 
of  bone  from  that  source),  are  almost  incurable  and 
sometimes  demand  amputation  or  wide  resection  of  the 
whole  area  including  the  condensed  bone  closing  the 
medullary  cavity.  A  resection  of  this  extent  produces 
crippling  shortening,  as  a  rule,  unless  a  bone  graft  can 
be  used.  If,  however,  the  operation  is  performed  at  an 
early  date  it  will  suffice  to  resect  one  wall  of  the  cavity, 
preserving  the  periosteum  covering  the  resected  callus 
and  thus  allowing  the  soft  parts  to  collapse  and  obliter- 


FRACTURES  IN  GENERAL  33 

ate  the  dead  space.  In  such  operations  all  the  old  gran- 
ulations and  cicatricial  tissue  lining  the  cavity  should 
be  carefully  excised  so  as  to  allow  the  periosteum  of 
the  side  removed  to  come  into  direct  contact  with  the 
callus  remaining  on  the  opposite  side. 

Vicious  union: 

Many  cases  of  vicious  union  demanding  correction 
come  to  base  hospitals.  They  are  often  complicated  by 
dead  bone  and  fistulse,  and  it  is  usually  advisable  to  get 
rid  of  the  latter  before  revising  the  union.  In  some 
cases  with  quiet  sinuses  showing  no  signs  of  active  in- 
fection, the  dead  bone  may  be  removed  and  the  fracture 
revised  at  the  same  operation;  but  the  wound,  under 
such  circumstances,  must  not  be  closed. 

The  methods  employed  to  revise  fractures  obviously 
depend  upon  the  site  and  the  nature  of  the  mal-union. 

Internal  fixation  is  seldom  necessary.  If  the  frag- 
ments cannot  be  maintained  in  good  relation  by  fixing 
the  limb  in  proper  position,  an  inlay  graft  may  be  of 
value.  Repair  of  fractured  callus  is  very  rapid  if  it  is 
fairly  recent.  After  several  months,  however,  it  loses 
its  vascularity  and  repair  is  slow,  so  that  operation  on 
these  cases  should  not  be  deferred. 

Non-union: 

In  true  non-union  the  ends  of  the  bones  become 
healed  over  and  the  medullary  cavity  plugged  with 
dense  callus.  Union  will  not  take  place  unless  this 
bone  plug  is  cut  away  and  the  medullary  cavity  made 
continuous.    Non-union  is  generally  caused  by  loss  of 


34      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

substance  (i.  e.,  removal  of  a  section  of  bone  either  by 
the  projectile  or  by  the  surgeon),  and  therefore,  if  all 
the  dense  material  forming  the  ends  of  the  bones  is  cut 
away,  considerable  shortening  results.  Hence  bone 
plating  should  not  be  used,  for  it  is  decidedly  unwise  to 
put  on  a  plate  and  leave  a  gap  between  the  bone  ends. 
The  treatment  for  these  cases  is  an  inlay  graft  by  the 
Albee  method.  The  channel  cut  to  receive  it  passes 
through  the  dense  ends  and  thus  the  medulla  is  made 
continuous  by  means  of  the  medullary  surface  of  the 
graft.  The  ends  of  the  fragments  are  not  removed, 
and  the  bone  is  therefore  not  shortened  by  the  opera- 
tion. 

Delayed  union: 

Delayed  union  is  best  treated  by  use  of  the  member. 
An  ambulatory  apparatus  such  as  the  Delbet  (Figs.  34, 
36  et  37)  may  be  employed  in  the  case  of  the  lower 
limbs.  Injections  of  blood  between  the  ends  of  the 
fragments  should  be  made  in  refractory  cases. 


CHAPTER    lY 

MECHANICAL  TREATMENT 

Since  the  beginning  of  the  war  mechanical  treatment 
(i.  e.  the  external  fixation  of  fractures)  has  passed 
through  several  phases.  The  tendency  has  led  steadily 
and  progressively  away  from  the  methods  of  absolute 
fixation  by  splints  of  wood,  metal  and  plaster  of  Paris 
toward  methods  in  which  the  main  principle  is  traction 
(extension  of  the  member  in  what  may  be  called  the 
physiological  direction  and  position).  With  this  latter 
method  the  old  rule  of  fixation  of  the  adjoining  articula- 
tions has  passed  into  obscurity. 

It  by  no  means  follows,  however,  that  plaster  of 
Paris  and  other  splints  should  be  done  away  with  en- 
tirely. They  are  of  the  greatest  value  for  certain  con- 
ditions, more  particularly  in  some  stages  of  convalesr 
cence  and  for  late  transportation. 

The  inadequacy  —  even  harmfulness  —  of  plaster, 
especially  the  circular  forms,  for  fresh  fractures,  be- 
came evident  very  early  in  the  war.  It  constricted  the 
limbs,  causing  sometimes  oedema,  sometimes  gas  gan- 
grene; or,  on  account  of  the  rapid  atrophy  of  the 
muscles,  the  splints  became  so  loose  as  to  afford  little 
support.  Pressure  sores  were  common.  Filth  col- 
lected under  the  plaster  and  abscesses  hidden  from 
sight  were  formed.  Dressings  were  difficult,  even  with 
the  most  skillful  bridging.    The  joints  stiffened,  and,  in 

35 


36      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

short,  the  condition  of  the  fractured  member  became 
deplorable. 

The  treatment  which  is  finding  greatest  favor  and 
gradually  becoming  generalized  is  suspension  of  the 
member  combined  with  traction.  A  simple  form  of 
splint  acting  as  a  cradle  (such  as  Hodgen's  for  the 
lower  extremity)  is  used  or  no  splint  at  all,  and  the 
limb  is  suspended  to  an  overhead  frame  with  or  without 
a  trolley  attachment.  Traction  is  applied  by  a  weight 
attached  to  a  cord  running  over  a  puUej'',  or  simply  by 
utilizing  the  weight  of  the  patient.  The  limb  is  sus- 
pended in  a  position  of  flexion,  rotation  or  abduction 
which  as  nearly  as  possible  coincides  with  that  of  physio- 
logical rest  for  the  opposing  muscles,  i.  e.  those  tend- 
ing to  cause  deformity.  This  position  of  physiological 
rest  is  a  most  important  object  to  attain,  for  with  it 
little  force  is  necessary  to  keep  the  fragments  in  place. 
Unfortunately,  on  account  of  wounds,  infection  and 
other  complications,  it  is  often  impossible  to  accomplish 
it,  but  it  should  always  be  the  goal  aimed  at. 

The  great  advantages  of  this  system  become  at  once 
apparent  to  one  who  has  struggled  with  other  methods 
— the  circulation  is  better,  the  wounds  are  accessible, 
union  is  if  anything  more  rapid,  and,  greatest  boon  of 
all,  the  patient  has  no  pain.  Furthermore,  the  articu- 
lations are  seldom  fixed  and  the  muscles  are  always  ac- 
cessible for  massage. 

Suspension  apparatus: 

In  order  to  suspend  fractured  limbs  some  sort  of  over- 
head frame  or  apparatus  is  necessary.     The  original 


MECHANICAL  TREATMENT  37 

Balkan  frame  consists  of  a  single  horizontal  bar,  longer 
than  the  bed,  supported  by  two  posts  set  on  foot  pieces 
in  order  to  make  the  apparatus  stable  and  allow  it  at 
the  same  time  to  be  moved  from  one  bed  to  another. 
This  frame  has  the  disadvantage  of  having  only  one 
bar,  of  being  too  low,  of  being  heavy  and  clumsy  and 
only  suitable  for  the  lower  extremity. 

The  frame  shown  in  Fig.  10  by  itself,  and  in  use  in 
the  figures  illustrating  the  method  of  suspending  the 
different  fractures,  is  free  from  most  of  the  above  de- 
fects and  has  proved  its  practicability.  It  has  the  dis- 
advantage of  being  difficult  to  attach  to  beds  that  are 
not  supported  on  legs  at  the  corners;  but  this  can  be 
overcome  by  nailing  longitudinal  bars  of  the  length  of 
the  bed  to  the  feet  of  each  pair  of  frames,  and  thus 
fastening  them  together  under  the  bed,  or  by  simply 
nailing  the  feet  to  the  floor.  The  frame  is  furnished 
by  the  Red  Cross  and  described  in  the  Army  Splint 
Manual,  but  in  case  of  delay  in  obtaining  a  supply  it 
can  readily  be  made  by  anyone  having  the  slightest 
knowledge  of  carpentry. 

The  apparatus  consists  of  two  similar  frames,  one  of 
which  is  tied  to  the  foot  and  the  other  to  the  head  of  the 
bed.  Each  frame  is  composed  of  two  uprights  united 
by  two  cross  members ;  the  lower  one  at  the  level  of  the 
top  of  the  mattress,  the  upper  one  far  enough  below  the 
upper  ends  of  the  uprights  to  avoid  splitting  of  the 
ends  of  the  latter  by  the  screws  or  bolts  which  are  used 
to  fasten  them  together.  The  upper  cross  member  is 
notched,  as  shown  in  the  diagrams,  to  receive  the  longi- 
tudinal bars,  which  are  also  notched.     Several  extra 


38      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

notches,  two  outside  and  two  inside  of  each  upright,  are 
made  in  the  cross  member  to  receive  the  longitudinal 
bars  in  the  proper  position  over  the  limb  to  be  sus- 
pended.    Only  two  notches  are  made  in  the  longitu- 


FiG.  10. — Suspension  frame  for  fractures. 

dinal  bars,  the  distance  between  them  being  the  exact 
length  of  the  bed.  The  interlocking  of  the  notches 
prevents  the  longitudinal  bars  from  slipping  and  makes 
the  entire  frame  rigid. 

The  end  frames,  as  will  be  seen  by  the  diagrams,  are 
made  in  the  shape  of  a  truncated  "A",  the  uprights  be- 
low being  separated  slightly  more  than  the  feet  of  the 


MECHANICAL  TREATMENT  39 

bed,  while  the  upper  ends  are  closer  together.  Each 
upright,  E-F  Fig.  10,  is  2  metres  (80  in.)  long.  The 
upper  cross  piece,  A-B,  is  1  metre  (40  in.)  long.  The 
lower  cross  piece,  C-D,  is  as  long  as  the  bed  is  wide,  so 
that  at  the  level  of  the  top  of  the  mattress  the  separation 
of  the  uprights  is  exactly  the  width  of  the  bed.  The 
lower  ends  of  the  uprights  are  separated  about  0.10 
metre  (4  in.)  more  than  at  the  level  of  the  mattress, 
which  brings  the  upper  ends  about  0.20  metre  (8  in.) 
nearer  together.  The  pieces  of  the  end  frames  are 
fastened  together  with  two  screws  or  carriage  bolts  at 
each  point.  Bolts  are  better  for  frames  to  be  knocked 
down  for  transportation. 

The  best  material  for  the  purpose  is  soft  white  pine 
free  from  knots;  this  does  not  split  and  the  eyes  or 
screws  of  the  pulleys  are  easily  inserted  into  it.  Any 
wood  may  be  used,  however.  Using  soft  pine  the 
author  has  found  material  0.021  metre  (%  in.)  thick 
and  0.05  metre  (2  in.)  wide  for  the  uprights  and  lower 
cross  piece  sufficient,  while  for  the  upper  cross  piece 
and  the  longitudinal  bars  slightly  wider  material,  0.06 
metre  (2%  in.),  should  be  used.  The  longitudinal 
bars  are  2.65  metres  (10  ft.  4  in.)  long  and  project 
over  the  ends  of  the  frames  so  as  to  allow  the  weighti^ 
to  hang  beyond  the  head  and  foot  of  the  bed. 

Suspension  is  effected  by  strong  cord  passing  through 
pulleys.  The  pulleys  used  are  the  ordinary  iron  ones 
found  in  any  hardware  shop,  furnished  with  a  screw  to 
fasten  in  the  wood  or  with  a  hook  which  is  hooked  into 
a  screw  eye. 

To  permit  the  patient  to  move  longitudinally  in  the 


40      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

bed,  as  m  the  change  of  posture  from  lying  down  to 
sitting,  it  is  advisable  to  have  a  short  bar  to  which  the 
limb  and  weights  are  hung,  and  which  moves  on  a  trolley 
attached  to  the  longitudinal  bar  of  the  main  frame. 
This  bar  is  made  of  a  piece  of  wood  0.30  metre  to  0.45 
metre  (12  in.  to  15  in.)  long  (Fig.  11),  in  the  bottom 


Fig.  11. — Detail  of  trolle}'  bar  for  suspending  the  lower 

limb. 

of  which  are  screwed  the  pulleys  through  which  the 
cords  for  the  suspension  pass.  Two  pulleys  are  screwed 
into  its  upper  side  and  run  on  an  iron  rod  10  millimetres 
(%  in.)  thick.  One  end  of  this  rod  is  bent  and  tied  to 
the  main  longitudinal  bar,  while  the  other  is  straight 
in  order  to  allow  it  to  engage  the  pulleys  and  is  passed 
through  a  hole  in  a  piece  of  strap  iron  bent  at  right 
angles,  which  is  in  turn  fastened  to  the  longitudinal  bar 
by  two  screws.  In  default  of  screw  pulleys  the  iron 
strap  hooks  furnished  by  the  Red  Cross  and  figured  in 
the  Army  Splint  Manual  may  be  used  for  attaching 
the  short  bar  (trolley)  to  the  long  longitudinal  bar. 
In  practice  it  has  been  found  that  the  trolley  attach- 


MECHANICAL  TREATMENT  41 

ment  is  very  important  for  suspending  the  lower,  but  is 
superfluous  for  the  upper  extremity. 

The  best  weights  are  cast  from  lead,  weigh  500 
grammes  each,  and  are  strung  on  an  iron  rod,  but  when 
they  hang  over  the  patient  in  such  a  position  that  he  or 
the  attendants  may  strike  against  them  it  is  better  to 
use  small  bags  of  shot,  each  holding  250  grammes, 
placed  in  a  larger  bag  of  strong  muslin.  These  smaller 
weights  permit  a  more  delicate  adjustment  for  the  arm 
and  forearm.  Failing  shot  or  lead,  sand  or  stones  may 
be  used. 

For  suspension  of  the  arm  a  simple  post  with  a  hori- 
zontal arm  may  be  used,  but  the  frames  just  described 
are  adapted  for  the  treatment  of  all  fractures. 

In  some  of  the  English  fracture  services  installed  in 
barracks  an  overhead  frame  is  constructed  as  part  of  the 
building.  It  consists  of  a  pair  of  longitudinal  bars,  of 
about  0.10  metre  X  0.075  metre  (4  in.  X  3  in.)  square 
section.  These  pass  over  the  beds  at  the  level  of  the 
eaves  on  each  side  of  the  barrack  and  extend  the  entire 
length  of  the  building.  The  bar  nearer  the  wall  is  at 
about  0.85  metres  (2  ft.  6  in.)  distance  from  it,  and  the 
other  at  2.25  metres  (7  ft.  6  in.)  ;  the  latter  thus  passes 
directly  over  the  bottom  of  each  bed.  Across  these, 
other  bars,  about  2.40  metres  (8  ft.)  in  length,  may  be 
placed  for  suspension  of  limbs.  To  provide  for  trac- 
tion, such  as  that  required  for  a  fracture  of  the  femur,  a 
post  is  used,  the  lower  end  of  which  is  fitted  into  a  step 
in  a  board  nailed  to  the  floor  in  front  of  the  foot  of  the 
bed,  and  the  upper  pinned  to  the  longitudinal  bar  over 
it.     A  number  of  steps  are  cut  in  the  board  so  that  the 


42      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

post  may  be  put  into  the  position  requisite  to  obtain  the 
desired  abduction  of  the  hmb.  The  foot  of  the  bed 
may  also  be  suspended  from  the  bar,  in  order  to  obtain 
the  necessary  traction  if  the  foot  is  attached  directly 
to  the  post,  or  counter-traction  if  a  weight  and  pulley 
are  used. 

This  overhead  construction  is  to  be  recommended  for 
fracture  services  installed  in  barracks,  but  it  must  be 
lower  than  the  eaves  or  it  is  impossible  to  arrange  the 
suspensions  without  a  stepladder.  2  metres  (6  ft.  6 
in.)  is  the  most  convenient  height. 

Methods  of  attaching  suspension  and  traction  apparatus 
to  the  limbs: 

The  several  methods  of  suspension  will  be  discussed 
under  the  headings  of  the  different  fractures. 

For  direct  attachment  of  the  apparatus  to  the  limb 
several  adhesive  substances  may  be  used.  The  most 
convenient  have  been  found  to  be  Sinclair's^  glue  or 
Heussner's^  hquid  glue,  both  of  which  are  painted 
^Formula  for  Sinclair's  glue  (from  the  British-Medical 
Journal,   August  26,  1916,  p.  301)  : 

Glue 50  parts 

Water 50       " 

^"       Glycerine 2       " 

Calcium  chloride 1        ** 

Thymol      . 1       " 

'  Formula  for  Heussner's  glue : 

Resin 50  parts 

Alcohol  90  0/0 50       " 

Venice    turpentine 1        " 

Benzine 10       " 


MECHANICAL  TREATMENT  43 

directly  on  to  the  limb  with  a  brush.  Bands  made  of 
Canton  flannel  and  furnished  with  straps  of  webbing 
for  tying  or  buckling  to  the  apparatus  are  then  immedi- 
ately applied.  A  supply  of  two  sizes  of  these  bands, 
one  for  the  leg  and  the  other  for  the  arm,  should  be 
made  and  kept  in  stock ;  they  are  readily  trimmed  to  the 
necessary  size  for  any  individual  case  and  are  more 
easily  applied  than  straps  made  of  diachylon  plaster, 
although  the  latter  is  one  of  the  best  and  least  irritating 
of  the  materials  that  can  be  used.  If  the  flannel  and 
webbing  bands  are  not  at  hand,  however,  stout  muslin 
or  several  layers  of  gauze  may  be  employed.  Rubber 
plaster  is  liable  to  slip  and  should  not  be  used. 

Sinclair's  glue,  being  an  aqueous  preparation,  is  well 
borne  by  the  skin.  It  adheres  firmly.  Sinclair  does 
not  shave  the  skin  but  strokes  the  hairs  upward  in 
applying  the  glue,  which  should  be  as  warm  as  can  be 
supported.  Heussner's  preparation  does  not  slip,  but  it 
occasionally  irritates.  When  using  either  glue  the  skin, 
as  for  all  impervious  plasters,  should  be  carefully 
cleaned  preliminarily  by  scrubbing  with  soap  and  water 
and  then  removing  all  traces  of  the  same  with  alcohol. 
No  antiseptic  other  than  alcohol  or  ether  should  be 
used. 

Traction: 

The  most  obvious  object  of  traction  is  to  overcome 
longitudinal  deformation,  i.  e.  overlapping.  It  also  to 
a  certain  extent  prevents  lateral  deformation,  i.  e.  angu- 
lation ;  and  if  it  is  made  in  the  proper  direction,  namely, 
in  that  of  the  axis  of  the  proximal  fragment,  the  ten- 


44      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

dency  to  angulation  is  so  slight  as  to  make  ordinary  fixa- 
tion unnecessary.  In  fact,  as  has  already  been  stated, 
the  time-honored  rule  of  fixing  the  adjacent  articulations 
no  longer  holds  and  in  most  instances  may  be  disre- 
garded. 

There  are  two  main  methods  of  producing  traction; 
one  by  a  force  exerted  continuously,  as  by  weights  and 
springs,  the  other  by  a  force  exerted  momentarily,  the 
resultant  length  being  retained  by  fixation  as  in  the  or- 
dinary application  of  the  Thomas  knee  splint.  In  the 
latter  method  there  is  no  way  of  estimating  the  tractive 
force,  the  only  guide  being  the  result  obtained.  Theo- 
retically this  would  seem  to  be,  and  is  thought  by  many 
to  be,  the  better  method.  The  objection  to  it  is  that  it 
is  difficult  to  maintain  what  has  been  gained  without 
producing  discomfort*  For  instance,  taking  the 
Thomas  splint  as  an  example,  the  length  of  the  limb  is 
maintained  by  attaching  the  traction  straps  to  the  distal 
end  of  the  splint  and  consequently  continuous  pressure 
is  exerted  by  the  upper  part  of  the  splint  against  the 
pelvis.  This  pressure  is  sometimes  insupportable.  To 
avoid  it  a  weight  may  be  attached  to  the  end  of  the 
splint  by  means  of  a  cord  running  over  a  pulley,  thus 
substituting  active  traction  for  the  passive  traction  of 
the  Thomas  splint  proper;  or  the  same  result  can  be 
accomplished  by  attaching  the  splint  to  a  fixed  point 
and  using  the  weight  of  the  patient  (the  bed  being  in- 
clined) ,  as  practised  by  Sinclair.  By  using  the  Thomas 
sphnt  in  the  manner  described  its  great  advantage  of 
being  a  self-contained  traction  sphnt  permitting  the 
patient  to  be  moved,  as  for  operations  or  X-rays,  is 


MECHANICAL  TREATMENT  46 

retained,  and  at  the  same  time  the  objection  of  con- 
stant pressure  against  the  pelvis  is  obviated.  If  the 
Thomas  splint  is  used  by  itself,  without  traction  on  the 
whole  splint,  care  should  be  taken,  in  tightening  the 
traction  from  time  to  time,  not  to  over-stretch  the  limb 
and  thus  ruin  the  knee-joint.  This  may  easily  happen 
on  account  of  the  impossibility  of  gauging  the  amount 
of  traction  employed.  The  loose,  weak  knees  so  often 
observed  in  convalescents  after  fracture  of  the  femur 
can  be  largely  avoided  by  due  regard  to  the  principles 
involved.  Many  surgeons  commit  the  error,  when  us- 
ing weights,  of  commencing  with  a  comparatively  small 
one  and  adding  to  it  until  the  desired  effect  is  produced ; 
not  realizing  that,  on  account  of  the  process  of  repair, 
each  day  makes  the  reduction  increasingly  difficult.  In 
this  manner  the  weight  is  increased  to  an  inordinate 
amount  and  continued  for  an  unnecessary  length  of 
time.  Consequently,  if  the  traction  is  made  through  a 
joint,  the  ligaments  will  be  gradually  stretched  and  the 
joint  may  be  irreparably  damaged.  The  correct  method 
is  to  use  a  weight  sufficient  to  reduce  the  fracture  in  the 
first  two  hours  and  to  then  decrease  it  to  the  amount 
just  necessary  to  maintain  the  position.  If  traction  is 
applied  in  this  way  little  trouble  will  be  experienced  in 
regard  to  the  joints. 

Traction  by  means  of  elastics  and  springs  is  difficult 
to  control,  is  not  well  borne,  and  is  in  general  unsatis- 
factory. 

Radiographic  control: 

It  is  impossible  to  treat  fractures  properly  and  inteUi- 


46      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

gently  without  frequent  radiographic  observations. 
This  is  particularly  true  of  gun-shot  fractures  because 
of  the  frequent  dressings  that  are  often  necessary  and 
that  cause  disturbance  of  the  mechanical  treatment. 

Radiographs  should  be  taken  directly  after  the  splints 
and  apparatus  have  been  applied  and  as  often  as  is 
necessary  to  verify  the  position  and  observe  the  course 
of  repair. 

It  is  unwise  and  impracticable  to  move  the  patient  to 
the  X-ray  room,  and  there  should  therefore  be  a  port- 
able apparatus  in  every  fracture  service.  In  hospitals 
where  there  are  large  wards  near  the  radiographic  de- 
partment wires  may  be  carried  from  the  latter  and  ex- 
tended throughout  the  length  of  the  wards,  and  to  these 
the  X-ray  tube  may  be  directly  connected. 

Nerve  lesions: 

All  cases  of  fracture  should  be  carefully  examined 
for  injuries  to  the  nerves  before  the  anaesthetic  is  given 
for  the  primary  operation,  so  that  they  may  be  sutured 
if  possible  at  that  time. 

Due  care  must  be  taken  in  the  after  treatment  of  these 
cases  to  prevent  deformation,  contractures  and  trophic 
disturbances  such  as  pressure  sores. 

When  there  is  a  lesion  of  the  musculo-spiral  nerve 
the  hand  must  be  kept  in  the  position  of  dorsiflexion  so 
that  the  flexor  muscles  may  function.  For  this  pur- 
pose, especially  during  convalescence,  the  Jones  cock-up 
splint  is  excellent;  it  bandages  to  the  flexor  surface  of 
the  forearm.  Another  good  cock-up  splint  may  be 
made  of  thin  sheet  metal  placed  on  the  dorsum  of  the 


MECHANICAL  TREATMENT  47 

forearm  and  wrist  and  reaching  just  to  the  heads  of  the 
metacarpals.  A  narrow  band  at  the  end  of  this  passes 
across  the  pahn,  holding  the  hand  up.  This  band  does 
not  interfere  so  much  in  grasping  objects  as  the  splint 
placed  on  the  flexor  surface. 


SECTION  II 

SPECIAL  FRACTURES 


CHAPTER   V 

DIAPHYSEAL  FRACTURES 

CLAVICLE  AND  SCAPULA 

Fractures  of  the  clavicle  and  scapula,  when  not  in- 
volving the  shoulder  joint,  are  treated  as  in  civil  prac- 
tice. Either  the  Sayre,  or  the  sling  and  body  bandage 
may  be  used.  It  is  often  impossible  to  use  a  typical 
method  on  account  of  the  position  of  the  wounds. 

The  chief  complications  of  these  fractures  are  inju- 
ries to  the  lung,  brachial  plexus  and  subclavian  vessels. 

HUMERUS 

Transport: 

Three  sphnts  are  furnished  by  the  Red  Cross  for 
splinting  the  humerus  for  transport.  These  are,  in 
order  of  preference:  Murray's  hinged  modification  of 
the  Thomas  traction  arm  splint  (Fig.  12  A),  the 
Thomas  traction  arm  splint  (Fig.  12  B),  and  Jones' 
humerus  traction  splint  (Fig.  13).  The  unmodified 
Thomas  splint  would  be  best  were  it  not  for  the  difficulty 
of  transporting  a  man  with  his  arm  extended  at  right 
angles  to  his  body. 

Neither  the  Murray  modification  nor  the  Jones  splint 
afford  abduction,  and  this  is  an  objection  to  their  use 
for  the  continued  treatment  of  high  fractures.     The 

51 


52      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

Jones  is  a  right  and  left  splint  and,  moreover,  several 
sizes  are  necessary. 

Failing  these  splints  a  fractured  humerus  may  be 
transported  satisfactorily  for  a  short  distance  by  using 
a  sling  and  body  bandage,  provided  that  the  axilla  and 


Fig.  12. 

A.  The     Thomas     traction     arm 

splint. 

B.  Murray's  modification  of  the 
Thomas  traction  arm  splint.  The 
bars  are  hinged  to  the  ring,  thus 
allowing  the  arm  to  hang  by 
patient's  side. 

side  are  well  padded  and  that  some  form  of  coaptation 
splint  is  used  to  prevent  angulation. 

In  both  the  Thomas  splint  and  Murray's  modifica- 
tion traction  is  made  with  the  arm  and  forearm  in  a 


DIAPHYSEAL  FRACTURES 


63 


straight  line,  i.  e.  with  the  elbow  extended.  It  should 
be  effected  by  means  of  adhesive  straps  attached  to  the 
skin  of  the  forearm.  In  case  these  cannot  be  applied, 
as,  for  instance,  when  there  are  wounds  of  the  forearm, 
a  clove  hitch  may  be  taken  with  a  bandage  about  a  heavy 
dressing  of  cotton  placed  on  the  wrist.     In  either  case 


Fig.  13. — The  Jones  traction  humerus  splint. 


the  straps  or  the  extremities  of  the  bandage  are  tied 
to  the  end  of  the  splint  after  having  been  first  placed 
one  over  the  other  under  the  bars.  Traction  is  then 
made  by  twisting,  %  means  of  a  short  stick  (Spanish 
windlass). 

In  using  the  Jones  humerus  splint,  traction  is  sup- 


54      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

posed  to  be  effected  by  adhesive  straps  attached  to  the 
skin  of  the  arm,  the  elbow  being  flexed ;  but  in  fractures 
of  the  lower  part  of  the  humerus  the  straps  obviously 
cannot  be  used,  and  a  hitch  must  be  taken  about  the 
elbow  with  a  bandage.  All  such  hitches  must  be  pinned 
in  order  to  prevent  their  drawing  tight  and  constricting 
the  parts. 


Fig.  14. — Thomas  traction  arm  splint  used  as  an  ambulatory 
splint.  Abduction  is  maintained  by  bending  another  Thomas 
splint  to  form  a  support. 

Operative  treatment: 

Should  be  conducted  as  laid  down  for  fractures  in 
general.  When  operated  on  before  infection  is  estab- 
lished, the  musculo-spiral  nerve,  if  divided,  should  be 
sutured. 


DIAPHYSEAL  FRACTURES 


55 


Mechanical  treatment: 

Much  ingenuity  has  been  expended  in  devising  am- 
bulatory sphnts  for  fractures  of  the  humerus,  but  none 
of  them  fulfill  all  the  requirements,  though  they  may 
render  excellent  service  after  union  has  commenced  and 
deformation  is  no  longer  likely  to  occur. 


Fig.  15. — Thomas  traction  arm  splint  used  for  bed  treatment 
of  fracture  of  the  humerus.  Traction  is  made  by  twisting 
the  bands  by  means  of  a  nail.  The  splint  may  be  suspended 
as  shown,  or  at  its  extremity  alone. 

Fractures  of  the  upper  half  of  the  bone  should  be 
treated  by  traction,  rotation  out  and  abduction,  accord- 
ing to  the  site.  Fractures  of  the  surgical  neck  usually 
require  extreme  abduction  and  rotation  out  (Fig.  19). 
This  position  brings  the  hand  to  a  level  above  that  of 
the  head — a  position  extremely  difficult  to  maintain 
with  an  ambulatory  apparatus. 

Fractures  of  the  lower  half  do  not,  as  a  rule,  require 
abduction  and  external  rotation,  and  could  be  satisfac- 
torily treated  with  the  Jones  splint  were  it  not  for  the 


56      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

difficulty  of  arranging  the  traction  in  presence  of  low 
wounds  and  of  keeping  the  splint  in  place.  The 
Thomas  splint  can  be  employed  for  any  fracture,  and 
may  be  used  as  an  ambulatory  splint  when  supported 


Fig.   16. — Principles   of  suspension   and  traction   for 

fractures  of  the  humerus : 

A.     High  fracture  of  the  humerus  for  which  adhesive 

strips  can  be  used  for  traction. 

as  shown  in  Fig.  14;  but  when  it  is  utilized  the  patient 
is  generally  kept  in  bed  and  the  end  of  the  splint  sus- 
pended (Fig.  15) .  The  objection  to  the  Thomas  splint 
and  its  modifications  is  that  the  elbow  is  kept  fixedly 
extended  and  traction  made  through  it,  and  on  account 
of  the  resulting  stiffness  the  period  of  convalescence  is 
greatly  lengthened  by  the  time  necessary  to  restore  the 
motion  of  the  joint.     Moreover,  the  ring  interferes  with 


DIAPHYSEAL  FRACTURES 


57 


the  dressings  when  the  wounds  are  in  the  neighborhood 
of  the  shoulder. 

On  the  other  hand,  treatment  by  suspension  and  trac- 
tion (without  any  spHnt),  as  carried  out  on  the  author's 


Low  fracture  for  which  adhesive  strips  cannot  be 
used.  In  this  case  a  band  is  placed  about  the  arm 
in  the  manner  shown;  in  order  to  prevent  its  slip- 
ping, and  to  keep  the  traction  in  the  axis  of  the 
humerus,  the  ends  of  the  band  are  crossed  over  in 
front  and  pinned  on  each  side  of  the  forearm.  It 
may  be  placed  directly  over  the  dressing  covering 
the  wound ;  when  there  is  no  wound  dressing  a  thiclc 
piece  of  cotton  should  be  placed  under  it,  but  for 
the  sake  of  clearness  neither  dressing  nor  cotton  has 
been  shown  in  the  drawing.  The  spreaders  which 
should  be  used  to  prevent  pressure  of  the  band  on 
the  epicondyles  have  also  been  omitted  from  the 
drawing. 


58      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

service  during  the  past  three  years,  is  adapted  to  all 
fractures  of  the  humerus,  including  those  entering  the 


Fig.  17. — Method  of  suspension  for  fracture  of 
the  humerus  or  elbow. 

Note  the  use  of  two  bars  over  the  arm,  the  ex- 
ternal one  being  employed  to  support  the 
forearm  and  to  maintain  the  abduction  and 
external  rotation  of  the  lower  fragment. 
The  traction  has  been  omitted  from  the 
drawing. 

shoulder  and  elbow  (Figs.  16,  17, 18  and  19) .    As  most 
cases  require  abduction  of  the  arm,  the  forearm  and  arm 


DIAPHYSEAL  FRACTURES 


59 


are  suspended  in  different  planes  in  relation  to  the 
longitudinal  axis  of  the  bed,  so  that  two  longitudinal 


Fig.  18. — A  simple  method  for  producing  traction  and 
at  the  same  time  regulating  abduction.  The  pulley 
for  the  weight  is  attached  to  an  upright  fixed  at  the 
end  of  a  rough  unplaned  board  which  is  slipped  in 
under  the  mattress.  The  desired  abduction  is  obtained 
by  adjusting  the  position  of  the  board. 

bars  must  be  used,  the  forearm  being  suspended  to  the 
outer.     The  distance  between  the  suspending  bars  is 


60      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

regulated  to  conform  with  the  desired  abduction  and 
the  outward  rotation  of  the  lower  fragment. 

Traction  must  always  be  made  in  the  axis  of  the 
upper  fragment.  The  position  of  the  latter  depends 
upon  the  site  of  fracture  and  the  preservation  of  the 
attachments  of  the  muscles,  and  varies  greatly.  Its 
exact  situation  can  only  be  determined  by  means  of 
X-rays;  the  apparatus  for  treatment  should  be  adjusted 
until  the  lower  fragment  is  in  hne  with  the  upper  frag- 
ment. Generally  speaking,  the  higher  the  fracture  the 
greater  the  abduction  and  outward  rotation  of  the  upper 
fragment  In  rare  cases  the  pectoral  may  adduct  the 
upper  fragment,  and  the  deltoid  draw  the  lower  frag- 
ment upward  on  its  outer  aspect. 

In  the  lower  fractures  traction  may  usually  be  made 
in  the  axis  of  the  bed  and  the  traction  pulley  attached 
to  a  cross  bar  joh  the  frame  at  the  foot  of  the  bed.  If 
more  abduction  is  necessarj^  the  method  illustrated  in 
Fig.  18  may  be  used.  By  this  device  an}^  desired  abduc- 
tion can  be  obtained  except  for  fractures  of  the  surgical 
neck,  in  which  the  fractured  surface  of  the  upper  frag- 
ment may  look  ahnost  directly  upward.  In  these  frac- 
tures the  arrangement  illustrated  in  Fig.  19  has  been 
found  efficient  and  surprisingly  comfortable. 

The  weight  necessary  for  traction  varies  with  the 
musculature  of  the  arm.  It  is  generally  from  1,500  to 
2,000  grammes. 

If  no  direct  suspension  of  the  arm  is  made  the  frag- 
ments tend  to  bow  backward.  To  prevent  this  a  broad 
sling,  nearly  equal  in  width  to  the  length  of  the  humerus, 
is  placed  under  the  arm,  which  is  then  suspended  as 


DIAPHYSEAL  FRACTURES  61 

shown  in  Figs.  17  and  18.  By  using  two  narrow  slings 
it  is  possible  to  vary  the  suspending  force  on  each  frag- 
ment as  desired ;  this  is  often  an  advantage,  but  it  neces- 
sitates careful  attention  as  regards  the  position  of  the 
slings  and  the  weight  attached  to  each,  and  for  this 
reason  a  single,^  broad  sling  is  more  practical.  This 
should  be  attached  to  a  stick  as  long  as  its  width  to  pre- 
vent it  from  wrinkling.  Eyelets  made  in  the  ends  of 
the  sling  slip  over  hooks  on  the  stick  and  permit  it  to  be 
easily  undone  for  dressing  purposes. 

The  weight  attached  to  the  sling  should  just  balance 
that  of  the  arm  proper,  while  the  amount  attached  to 
the  forearm  should  correspond  to  the  weight  of  the 
latter.  If  a  heavier  weight  be  applied  to  the  forearm 
the  fragments  will  tend  to  bow  backward,  and  con- 
versely, if  the  weight  be  lighter  they  will  tend  to  bow 
forward  About  1,500  grammes  are  necessary  for 
each  (i.  e.  arm  and  forearm) . 

The  slings  may  be  made  of  Canton  flannel  backed 
with  muslin  to  give  them  rigidity  and  prevent  wrinkling, 
but  when  continued  irrigation  or  wet  dressings  are  em- 
ployed they  are  best  made  of  rubber  sheeting. 

The  method  of  arranging  the  adhesive  strips  for  sus- 
pension of  the  forearm  is  shown  in  Fig.  16.  The  strips 
are  applied  to  the  sides  of  the  limb  and  must  not  overlap 
(i.  e.  encircle  it)  on  account  of  the  danger  of  constric- 
tion in  the  event  of  swelling  of  the  member.  The  pieces 
of  webbing  attached  to  them  are  fastened  by  buckles  to 
a  spreader  made  of  thin  board,  0.125  metre  (5  in.)  long 
X  0.10  metre  (4  in.)  wide,  to  the  center  of  which  a  cord 
is  fixed.     To  the  ends  of  this  spreader  are  attached 


62      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

bands  of  elastic  webbing,  0.02  metre    (%  in.)    wide; 
these  support  a  round  bar  of  wood  at  a  height  which  puts 


Fig.  19. — Position  of  extreme  abduction  and  external  rotation 
necessary  in  the  treatment  of  some  fractures  at  the  surgical 
neck  of  the  humerus. 


it  just  within  reach  of  the  fingers,  so  that  the  patient 
can  pull  it  down  into  the  grasp  of  the  hand  and  thus 


DIAPHYSEAL  FRACTURES  63 

exercise  the  fingers — an  arrangement  which  is  of  special 
value  if  the  musculo-spiral  nerve  has  been  injured. 

Traction  to  the  lower  fragment  of  the  humerus  is 
most  efficiently  made  by  means  of  adhesive  or  glued 
strips.  When  wounds  are  present  below  the  middle  of 
the  arm,  however,  they  cannot  be  applied  unless  such 
wounds  happen  to  be  in  the  antero-posterior  plane  of 
the  limb.  To  overcome  the  difficulty  a  band  of  muslin 
0.08  metres  (3  in.)  wide  can  be  passed  about  the  arrh 
and  elbow,  somewhat  in  the  manner  of  the  Hennequin 
hitch  for  fractures  of  the  femur.  The  center  of  the 
band  is  applied  to  the  back  of  the  arm  just  above  the 
elbow,  and  the  ends,  after  crossing  in  front,  pass  to  each 
side  of  the  forearm  as  shown  in  the  illustration  (Fig. 
16)  ;  they  are  then  pinned  back  to  the  middle  portion 
of  the  band,  so  as  to  pass  along  the  sides  of  the  elbow 
and  bring  the  traction  into  the  axis  of  the  humerus,  as 
otherwise  the  band  would  tend  to  force  the  lower  frag- 
ment forward.  As  an  alternative,  a  band  like  a  wristlet 
may  be  placed  just  above  the  elbow  and  side-straps  at- 
tached to  it;  it  is  convenient  to  have  these  made  so  that 
they  can  be  laced  on.  Either  variety  may  be  placed 
directly  over  the  dressing  on  the  wound,  but  if  such 
dressing  does  not  extend  to  the  elbow  the  latter  should 
be  well  padded  with  absorbent  cotton. 

Patients  should  be  encouraged  to  move  the  elbow, 
wrist  and  fingers  actively,  and  they  should  be  passively 
moved  and  massaged  daily. 

No  splints  of  any  kind  are  applied  to  the  arm,  and 
although  the  patients  move  freely  in  bed,  lying  down 
and  sitting  up  (even  out  of  bed  in  a  chair),  there  is  no 


64      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

pain  and  union  takes  place  rapidly  without  deformity. 

As  soon  as  union  is  firm  the  patient  is  allowed  to  get 
up  with  his  arm  in  a  sling ;  this  must  be  removed  several 
times  a  day,  however,  and  the  patient  encouraged  to  ex- 
ercise all  the  motions  of  the  shoulder  and  elbow  joints. 

In  fractures  treated  by  suspension  firm  union  has 
been  repeatedly  observed  within  25  days  in  uninfected 
cases,  and  patients  have  been  able  to  use  their  arms  in 
four  weeks  from  reception  of  the  wound.  In  cases  of 
delayed  union  caused  by  loss  of  bone  or  infection  there 
has  been  no  tendency  to  the  production  of  pseudarthro- 
sis,  as  might  be  supposed  would  result  from  the  absence 
of  fixation.  On  the  contrary,  union  has  appeared  to 
be  more  rapid,  which  is  explained  by  the  preservation, 
during  the  treatment,  of  function  and  normal  circula- 
tion. 

EADIUS  AND   ULNA 

Fractures  of  the  forearm  are  extremely  difficult  to 
treat.  In  fractures  of  both  bones,  on  account  of  the 
usual  comminution  and  projection  of  splinters  into  the 
tissues,  cross  union  or  interference  of  callus  is  apt  to 
occur.  Moreover,  because  of  the  numerous  muscles 
and  tendons  it  is  difficult  to  secure  adequate  drainage 
and  infection  may  cause  lamentable  loss  of  function 
from  sloughing  of  tendons  and  from  cicatricial  fusions. 

Transport: 

Murray's  modification  (Fig.  12  B)  of  the  Thomas 
traction  arm  splint  is  the  best  splint  for  transport. 
Traction  is  applied  by  one  of  the  methods  illustrated  in 


DIAPHYSEAL  FRACTURES  65 

Fig.  21  or  by  a  hitch  with  a  bandage  over  a  cotton  dress- 
ing about  the  wrist.  The  ends  of  the  strips  are  simply 
passed  about  the  bars  of  the  sphnt  and  tied  to  its  end 
(as  ah'eady  described  for  fractures  of  the  humerus), 
and  the  traction  is  tightened  by  twisting  the  strips.  The 
traction  should  be  arranged  so  as  to  keep  the  hand 
supinated.  A  bandage  is  placed  about  the  splint  and 
arm. 

Operative  treatment: 

Fractures  of  the  radius  and  ulna,  although  not  so 
dangerous  to  life  as  others,  are  the  most  dangerous  of 
all  as  regards  loss  of  function.  The  losing  of  the  use  of 
a  hand  is  much  more  serious  than  that  of  a  leg,  and  the 
surgeon  must  not  only  aim  at  preserving  a  forearm  and 
hand  but  at  preserving  their  functions  also ;  this  cannot 
be  the  case  if  all  the  tendons  and  nerves  are  embedded 
in  a  cicatricial  mass,  and  such  fractures  should  therefore 
receive  the  earliest  possible  attention  in  order  to  avoid 
infection.  Rifle  ball  fractures  with  punctate  orifices 
are  the  only  ones  which  should  not  be  operated  upon. 

Were  it  not  for  the  fact  that  non-union  of  these  bones 
is  common  after  resection,  primitive  resection  of  their 
fractures  would  have  fuller  indications  than  in  the  case 
of  breakage  of  any  other  diaphysis. 

When  operating  before  the  establishment  of  infection 
the  incisions  should  be  free  and  the  dissection  carefully 
carried  down  between  the  muscles  and  tendons.  All 
fragments  driven  into  the  muscles  must  be  carefully 
sought  for  and  removed,  and  those  which  have  remained 
attached  should  be  pressed  back  into  place  if  possible. 


66      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

The  muscles  and  tendons  should  be  trimmed  and  re- 
paired, or  cross  sutured  if  long  segments  have  been  de- 
stroyed. Fine  chromicized  gut  should  be  used;  plain 
cat-gut  will  not  hold,  and  heavy  chromicized  gut  will 
have  to  be  removed  if  suppuration  should  occur.  Nerves 
should  be  sutured  if  possible.  The  wounds  should  be 
partially  closed;  tight  suturing  of  the  fascia  must  be 
avoided.  Drainage  tubes  should  never  be  used,  as  they 
produce  sloughing  of  the  tendons  by  pressure. 

When  infection  is  already  established  the  operation 
should  be  confined  to  providing  drainage  and  removing 
detached  bone  and  foreign  bodies,  especially  clothing. 
Projectiles  themselves  do  not  provoke  suppuration  un- 
less clothing  is  attached  to  them,  and  therefore,  if  they 
are  small  and  not  easily  located,  the  operation  should 
not  be  prolonged  to  find  them.  For  drains  vaselined 
gauze  should  be  used. 

Mechanical  treatment: 

Traction  is  exceedingly  important  in  the  treatment  of 
fractures  of  the  radius  and  ulna,  even  when  only  one 
bone  is  broken.  This  is  especially  true  of  fractures  of 
the  lower  part  of  the  radius,  as  in  these  cases  abduction 
of  the  hand  due  to  shortening  of  the  radius  is  apt  to 
occur,  causing  marked  loss  of  function. 

It  is  wiser  to  treat  these  patients  in  bed  until  repair 
is  well  advanced,  particularly  if  the  fracture  is  infected. 
By  keeping  the  patient  in  a  reclining  position,  with  the 
arm  and  forearm  suspended,  the  circulation  is  greatly 
improved  and  repair  hastened. 

The  entire  limb  may  be  placed  in  a  Thomas  arm 


DIAPHYSEAL  FRACTURES  67 

splint  and  suspended.  It  will  be  found  better  to  use 
independent  traction  by  weight  and  pulley  (Fig.  21) 
than  to  attach  the  traction  strips  to  the  splint,  as  in  the 


Fig.  20. — Method  of  using  bent  Thomas  traction 
arm  splint  for  treating  fractures  of  the  radius 
and  ulna.  Traction  is  made  by  a  glove  glued 
to  the  hand,  and  counter-traction  furnished  by 
a  band  around  the  arm  and  splint  just  above 
the  elbow. 

latter  case  the  arm  will  have  to  rest  at  right  angles  to 
the  body.  On  account  of  the  carrying  angle  of  the  el- 
bow, it  is  usually  advisable  to  bend  the  Thomas  splint 
at  the  elbow  (Fig.  20).  The  Jones  humerus  traction 
splint  may  be  used  instead  of  the  bent  Thomas,  but  it 
generally  needs  considerable  re-bending  and  adjust- 
ment. 


68      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

The  simple  cradle  shown  in  Figs.  21  and  25  C  has 
been  found  satisfactory.  It  consists  of  two  parallel 
steel  rods,  0,009  metre  (%  in.)  thick  and  0.40  metre 
(16  in.)  long,  fastened  together  by  two  bows  of  rod 
0.004  (3/16  in.)  thick,  so  that  the  distance  between  the 
parallels  is  about  0.15  metre  (6  in.).  This  distance 
can  be  easily  regulated  by  bending  the  bows. 

No  matter  what  splint  is  used  the  forearm  is  sup- 
ported in  the  same  manner  as  for  the  lower  extremity, 
on  pieces  of  10  centimetre  (4  in.)  flannel  bandage 
doubled  across  the  bars  and  fastened  at  one  side  with 
clips  or  pins.  When  wet  dressings  are  used  these  bands 
should  be  made  of  perforated  rubber  sheeting.  Care 
should  be  taken  to  keep  such  bands  or  slings  taut  and 
smooth  so  that  the  limb  is  evenly  supported. 

Traction  is  effected  by  means  of  glued  or  adhesive 
strips  (Fig.  21  A),  or  by  Sinclair's  method  of  gluing  a 
cotton  glove  on  to  the  hand  (Fig.  21  B).  This  clever 
and  very  satisfactory  arrangement  consists  of  an  ordi- 
nary cotton  glove  to  which  small  curtain  rings  are 
attached  at  the  tips  of  the  fingers  by  means  of  cotton 
tape,  the  latter  being  sewed  along  the  entire  length  of 
the  fingers  to  reinforce  them.  A  narrow  cord  is  then 
laced  through  the  rings  and  over  a  round  stick  which 
acts  as  a  spreader  and  thus  equalizes  the  tension  on  the 
fingers.  The  spreaders  should  be  long  enough  to  en- 
gage with  the  bars  of  the  splint,  so  as  to  prevent  the 
hand  from  turning  and  to  maintain  it  in  supination. 

Counter-traction  is  provided  for,  when  the  bent  elbow 
position  is  adopted,  by  a  hitch  about  the  forearm  at  the 
bend  of  the  elbow  and  over  a  cotton  dressing,  as  shown 


DIAPHYSEAL  FRACTURES 


69 


in  Fig.  21;  or,  when  a  bent  Thomas  sphnt  is  used,  by- 
attaching  the  cord  directly  to  the  spHnt.     A  weight  of 


Fig.  21. — Suspension  cradle  for  fractures  of  the  radius  and 
ulna,  and  methods  of  installing  traction  and  counter-trac- 
tion. 

A.  Traction  by  means  of  glued  or  adhesive  strips  for  high 
fractures.  A  spreader  is  used,  to  which  the  traction  strips 
are  attached. 

B.  Sinclair's  method  of  using  a  cotton  glove  glued  to  the 
hand.  Note  the  manner  of  attaching  the  rings  to  the  fingers 
of  the  glove  by  means  of  cotton  tape,  and  the  equalizing  of 
tension  by  lacing  the  cord  through  the  rings  and  over  the 
spreader.  Counter-traction  is  made  by  the  band  hitched 
about  the  forearm  at  the  bend  of  the  elbow.  The  dressing 
of  cotton  which  should  be  placed  under  this  band  has  been 
omitted  from  the  sketch  for  the  sake  of  clearness. 

from  1,000  to  1,500  grammes  is  usually  sufficient  for 
traction. 

The  consensus  of  opinion  is  in  favor  of  treating  frac- 


70      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

tures  of  the  forearm  and  particularly  those  of  the 
radius,  with  the  hand  in  full  supination,  both  on  account 
of  the  danger  of  cross  union  and  because  the  movement 
of  pronation  is  then  more  easily  acquired  in  case  of  in- 
complete ankylosis  of  the  radio-ulnar  articulation.  The 
hand  is  much  more  useful  in  the  supinated  position, 


Fig.  22. — Van  de  Veld's  splint  for  fractures  of  the  forearm. 

since  it  is  brought  into  the  pronated  position  by  abduc- 
tion of  the  elbow.  This  last  point  must  be  borne  in 
mind  during  the  treatment  of  the  fracture  in  order  that 
the  mistake  may  be  avoided  of  over-supinating  the  hand 
when  suspending  the  arm  with  the  elbow  abducted  from 
the  body ;  for,  when  the  arm  is  abducted  to  a  right  angle, 
the  hand  is  in  full  supination  when  the  thumb  is  point- 
ing upward  and  the  palm  is  directly  mesally. 


DIAPHYSEAL  FRACTURES 


71 


When  repair  is  well  under  way  and  the  condition  of 
the  wound  permits,  an  ambulatory  splint  is  desirable. 
If  traction  is  still  necessary  a  bent  Thomas  arm  splint 
may  be  used  and  the  traction  cords  attached  to  the  end 
of  the  splint  (Fig.  20).  In  this  case  it  is  well  to  use 
an  elastic  cord  to  take  up  the  slack  of  the  bandages 


Fig.  23. — Sinclair's  splint  for  fracture  of  the  forearm. 

which  fasten  the  arm  into  the  splint.  When  traction 
is  no  longer  required  the  best  splints  are  then  the  Van 
de  Veld  and  Sinclair  (Figs.  22  and  23).  These  are 
alike  in  principle.  The  Van  de  Veld  consists  of  two 
pieces  of  wooden  splint  board,  of  which  one  lies  on  the 
palmar  aspect  of  the  forearm  and  the  other  on  the 
lateral  aspect  of  the  arm,  the  two  being  connected  by  an 
adjustable  metal  hinge  at  the  elbow.  The  Sinclair  is 
made  of  metal,  and  the  two  pieces  are  fastened  together 


72      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

by  a  curved  rod.  With  both,  pronation  is  prevented 
by  the  arm  piece  being  on  the  outside  of  the  arm. 

Circular  plaster  splints  should  never  be  used  for  frac- 
tures of  the  forearm  because  the  circular  turns  draw 
the  bones  together. 

Repair  is  fairly  rapid  in  fractures  of  the  forearm,  and 
the  bones  should  unite  within  three  or  four  weeks.  It  is 
exceedingly  important  that  the  fingers  be  moved  twice 
daily  throughout  treatment,  and  the  splints  should  never 
pass  beyond  the  heads  of  the  metacarpals.  Active  mo- 
tion of  the  fingers  must  also  be  encouraged ;  a  few  days 
of  fixation  often  produce  irreparable  stiffness. 

METACARPUS   AND    PHALANGES 

Gun-shot  fractures  of  these  small  bones  are  nearly 
always  accompanied  by  loss  of  substance  and,  in  the 
case  of  the  phalanges,  generally  demand  amputation. 
In  some  instances  resection  of  portions  of  the  hand  is 
necessary.  Such  operations  are  atypical  and  cannot  be 
described.  In  general,  on  account  of  the  serious  aggra- 
vation of  the  wounds  by  infection,  it  is  wise  to  remove 
all  lacerated  tissues  and  strive  for  asepsis ;  by  acting  in 
this  way  plastic  operations  and  tendon  sutures  may  be 
successful  which  could  never  be  performed  later. 

In  cases  not  needing  resection,  fractures  of  the  meta- 
carpals may  be  treated  by  bandaging  the  hand. over  a 
rubber  ball  a  little  larger  than  the  ordinary  tennis  ball. 
Some  cases  are  benefited  by  traction;  this  can  be  at- 
tached by  gluing  on  glove  fingers  (Fig.  21)  and  plac- 
ing the  arm  in  one  of  the  traction  splints  for  the  forearm. 
When  traction  is  employed  the  hand  should  be  sup- 


DIAPHYSEAL  FRACTURES  73 

ported  on  a  ball  in  order. to  preserve  the  normal  curve 
of  the  bone. 

FEMUR 

Gun-shot  fractures  of  the  femur  are  the  most  serious 
of  all  fractures  of  the  limbs.  The  mortahty  is  high: 
firstly,  from  hemorrhage  and  shock;  secondly,  from 
acute  infection  (particularly  gas  gangrene)  ;  and 
thirdly,  from  chronic  sepsis  and  its  complications.  In 
all  cases  convalescence  is  long  and  average  results  are 
poor. 


Fig.     24.  —  Thomas 
traction  leg  splint. 
Transport: 

Traction   during  transport   is   absolutely   essential. 


74     GUN-SHOT  FRACTURES  OF  EXTREMITIES 

The  Thomas  traction  leg  splint  (Fig.  24),  or  the  half 
ring  modification  (Fig.  25  A)  should  be  used.  The 
ring  of  the  regular  Thomas  splint  is  passed  over  the 
limb,  and  for  this  reason  is  made  much  larger  than  that 
of  the  ambulatory  splint.^  The  half -ring  model  is  ap- 
plied to  the  back  of  the  limb  and  is  held  in  place  by 
a  strap  which  passes  over  the  groin.  Ordinarily  three 
sizes  of  the  regular  Thomas  splint  are  furnished,  but 
only  one  size  of  the  half -ring  modification  is  supplied. 
For  transportation  from  the  field  the  splints  are 
applied  over  the  clothing  and  before  the  wounds  are 
dressed.  Traction  is  then  attached  to  the  foot,  over 
the  boot,  either  by  means  of  the  gaiter  which  is  issued 
with  the  splint,  or,  better,  by  Pouliquen's  method  of 
using  a  bandage,  as  follows: — 2  lengths  of  0.075  metre 
(3  in.)  bandage,  each  1  metre  long,  are  applied  to  the 
ankle  by  the  middle  of  each,  one  to  one  side  of  the  ankle, 
the  other  to  the  other  side;  the  ends  are  then  carried 
across  the  foot,  one  in  front  over  the  instep  and  the 
other  behind  over  the  heel:  when  drawn  upon  the  ends 
hug  the  foot  snugly  and  do  not  slip.  The  ends  of  the 
gaiter  straps  or  of  the  bandage  are  passed  over  and 
under  the  bars,  and  tied  about  the  notch  at  the  end  of 
the  splint.  In  tying  them  the  full  strength  of  the  sur- 
geon must  be  exerted  in  order  to  crowd  the  ring  well 
up  against  the  pelvis  and  pull  the  leg  down  into  the 
splint.  If  the  traction  is  insufficient  a  stick  or  nail  a 
little  longer  than  the  width  of  the  splint  should  be 
passed  between  the  straps  at  the  end  of  it  and  twisted 
in  the  manner  of  the  Spanish  windlass.  The  clothing 
is  then  cut  from  about  the  wounds  and  they  are  dressed. 

^Page  94. 


DIAPHYSEAL  FRACTURES 


76 


A  piece  of  coaptation  or  wire  splinting  is  placed  behind 
the  limb  (Fig.  27),  care  being  taken  to  pad  it  well  at 
the  back  of  the  knee.  By  taking  hitches  with  a  band- 
age about  the  bars  of  the  Thomas  splint,  a  sort  of  sling 
suspension  is  formed  and  at  the  same  time  the  leg  is 


Fig.  25 

A.  Half-ring  modification  of  the  Thomas  traction  leg 
splint.  On  account  of  the  hinge  the  splint  can  be 
used  for  either  limb. 

B.  Hodgen's  leg  splint. 

C.  Frame  used  for  suspension  of  fracture  of  the  fore- 
arm. 

prevented  from  moving  forward  in  the  splint.  Several 
turns  of  the  bandage  shoidd  be  passed  around  both 
splint  and  limb,  as  shown  in  the  illustration,  and  a  figure 
of  eight  made  about  the  foot  so  as  to  support  it  com- 
fortably. On  the  stretcher  the  limb  should  be  sus- 
pended as  shown  in  Figs.  26  and  27.  If  the  patient 
is  to  be  evacuated  in  a  Ford  ambulance  the  stretcher 
suspension  must  be  placed  over  the  middle  of  the  leg 


76      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

in  order  to  raise  the  foot  enough  to  clear  the  tailboard 
of  the  car. 

Traction  by  the  gaiter  or  by  a  hitch  over  the  boot  is 
merely  provisional,  however,  and  only  to  be  employed 
for  short  trips.     The  use  of  the  gaiter,  even  with  a 


Fig.  26. — Method  of  attaching  end  of 
splint  to  stretcher  suspension.  If  the 
patient  is  to  be  transported  in  a  Ford 
ambulance  the  stretcher  suspension 
must  be  placed  over  the  middle  of  the 
leg  so  as  to  raise  the  foot  above  the  tail 
board  of  the  car.  (From  the  British 
Army  Instructions.) 

heavy  cotton  dressing  under  it,  is  unsatisfactory  for  the 
strong  tension  necessary  for  fractures  of  the  thigh,  as 
it  is  apt  to  cause  pressure  sores,  especially  above  the 
heel.  At  the  time  of  operation  permanent  traction  for 
treatment  should  be  provided.  This  may  be  applied 
by  means  of  adhesive  or  glued  strapping,  the  Codavilla 


DIAPHYSEAL  FRACTURES 


77 


pin  or  the  Ransohoff  tongs;  but  if  the  patient  is  to  be 
evacuated  again  strapping  must  be  used. 

If  wounds  preclude  the  use  of  the  Thomas  splint  in 
the  case  of  high  fractures,  the  long  Liston  splint  should 
be  employed.     There   is   no   provision   in  the   Liston 


Fig.  27. — Method  of  applying  the  Thomas  traction  leg  splint. 
The  splint  is  passed  over  the  clothing  and  the  traction  is 
applied  before  the  wound  is  dressed.  The  clothing  is  then 
cut  from  the  region  of  the  wound ;  it  is  dressed,  and  a  coap- 
tation splint,  well  padded  under  the  knee,  is  placed  behind 
the  limb.  The  bandage  is  then  applied  so  as  to  prevent  any 
motion  of  the  limb  either  backward  or  forward,  and  to  form 
a  figure  of  eight  about  the  foot.  The  end  of  the  splint  is 
hung  to  the  stretcher  suspension  so  as  to  prevent  lateral 
swaying.     (From  the  British  Army  Instructions.) 

splint,  as  supplied,  for  traction,  but  this  can  be  pro- 
vided by  attaching  the  foot  to  the  lower  end  of  the 
splint  and  then  taking  up  the  counter-traction  by  pass- 
ing a  padded  cord  from  the  upper  end  between  the 
thighs  as  a  perineal  band.     Failing  the  Liston  splint. 


78      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

the  same  object  may  be  attained  by  utilizing  one  side  of 
a  Bradford  frame  or  a  stretcher  pole. 

The  combination  of  the  long  Liston  splint  and  the 
Delorme  aluminium  gutter  splint  with  traction,  devised 
by  Pouliquen,  is  extremely  efficient  for  transport  as  it 
provides  both  fixation  and  traction. 

When  a  patient  with  fracture  of  the  femur  has  to  be 
evacuated  after  the  primary  operation,  a  Thomas  splint 
should  be  used  and  the  traction  strapping  freshly  and 
carefully  arranged.  A  wire  foot  piece  as  shown  in  Fig. 
27  (but  reversed)  should  be  applied  to  the  splint  and 
the  foot  bandaged  to  it,  in  order  to  prevent  foot  drop. 
The  slings  and  bandages  about  the  splint  must  be  very 
carefully  adjusted  so  as  to  avoid,  in  so  far  as  possible, 
the  slightest  motion  at  the  site  of  fracture.  It  is  ex- 
tremely unwise  to  transport  these  cases  before  union 
has  commenced,  as  the  slightest  fresh  traumatism  (so 
easily  caused)  may  light  up  infection. 

Occasionally  it  may  seem  best  to  use  plaster  of  Paris 
splinting  for  transport,  particularly  in  cases  of  high 
fracture  and  fracture  of  the  neck  in  which  a  position 
of  abduction  should  be  maintained.  These  splints  are 
difficult  to  put  on  and  must  be  accurate  to  be  efficient. 
In  order  to  maintain  abduction  the  pelvis  must  be  fixed 
and  the  sound  limb  therefore  included  in  the  splint,  and 
the  latter  should  also  extend  up  over  the  lower  ribs  on 
each  side  of  the  body.  To  avoid  the  suffering  caused  to 
the  patient  by  keeping  him  too  long  on  the  pelvic  rest, 
it  is  wise  to  cut  out  forms  of  fifteen  to  twenty  thick- 
nesses of  crinoline  for  the  parts  of  the  splint  which  must 
be  strongest  (i.  e.  one  piece  for  the  abdomen,  groin  and 


DIAPHYSEAL  FRACTURES  79 

anterior  parts  of  the  thigh,  and  another  and  longer 
piece  for  the  side  of  the  body,  outer  side  of  the  thigh  and 
the  leg).  These  forms  should  be  impregnated  with 
plaster  cream  and  bandaged  on  with  the  ordinary  plas- 
ter bandages.  It  is  well  to  bandage  in  a  cross  stick  to 
keep  the  thighs  apart. 

Operative  treatment: 

Amputation. — As  the  function  of  the  lower  ex- 
tremity is  essentially  that  of  weight  bearing,  unless 
there  is  hope  of  retaining  a  strong  limb  it  is  wiser  to  am- 
putate than  to  run  the  risk  of  a  prolonged  and  often 
stormy  convalescence.  Consequently  the  surgeon 
should  not  take  chances  in  fractures  of  the  thigh  that 
would  be  perfectly  justifiable  in  fractures  of  the  upper 
extremity,  the  preservation  of  the  slightest  portion  of 
which  is  of  value. 

The  indications  for  amputation  may  be  divided  into 
two  groups:  the  first,  for  immediate  amputation;  the 
second,  for  amputation  after  infection  has  become  estab- 
lished. Immediate  amputation  should  be  done  for  (1) 
extensive  loss  of  groups  of  muscles,  especially  if  the 
sciatic  nerve  is  severed,  (2)  division  of  both  femoral 
and  internal  saphenous  veins,  (3)  excessive  comminu- 
tion of  the  greater  portion  of  the  shaft — 20  centimetres 
or  more,  (4)  shock,  when  it  is  deemed  that  the  patient 
will  not  survive  the  primary  operation  described  below, 
since  amputation  is  shorter  and  less  shocking  and  the 
convalescence  quicker.  The  indications  for  amputa- 
tion in  the  case  of  established  infection  are  (1)  injury 
to  the  femoral  artery  or  vein  requiring  ligation,    (2) 


80      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

gas  gangrene  when  more  than  one  group  of  muscles  is 
extensively  involved,  (3)  extensive  fracture  of  the  dia- 
physis  communicating  with  the  knee  joint  when  the 
latter  is  also  suppurating,  (4)  multiple  wounds  threat- 
ening life,  (5)  incurable  chronic  osteomyelitis.  The 
drifting  policy  should  not  be  followed  in  septic  cases; 
amputation  should  be  done  before  visceral  degeneration 
takes  place. 

PuiMAEY  Operations. — The  primary  operation  is 
long  and  severe,  and  the  patient  must  have  recovered 
from  shock  before  it  is  undertaken.  Nitrous  oxide  oxy- 
gen anaesthesia  should  be  used.  The  wounds  should 
be  enlarged  so  as  to  obtain  free  access  to  their  deepest 
parts — transverse  incisions  should  be  avoided  if  pos- 
sible. Flexion  of  the  thigh  on  the  pelvis  relaxes  the 
muscles  and  facilitates  retraction.  The  danger  of  in- 
fection is  largely  due  to  the  extensive  destruction  of 
muscles  and  consequently  great  care  must  be  taken  to 
remove  all  devitalized  tissue.  Greater  attention  than 
usual  should  be  paid  to  the  perfection  of  h^emostasis  on 
account  of  the  depth  of  the  wounds  and  the  consequent 
danger  of  retention  of  blood. 

Dependent  counter-drainage  should  be  provided  in  all 
operated  fractures.  The  drainage  incision  should  be 
made  at  the  outer  border  of  the  biceps  and  should  extend 
to  above  the  site  of  fracture,  so  as  to  avoid  pocketing 
when  the  thigh  is  flexed. 

Immediate  suture  of  the  wounds  is  not  to  be  recom- 
mended except  in  selected  cases.  Up  to  the  time  of 
writing  primary  suture  of  the  wounds  has  succeeded  in 
only  about  15  per  cent,  of  fractures  of  the  femur.  They 


DIAPHYSEAL  FRACTURES  81 

should  be  left  for  delayed  primary  or  secondary  suture. 

Mechanical  treatment: 

Splints. — The  splints  furnished  for  treatment  of 
fractures  of  the  femur  are  the  Thomas  leg  traction,  the 
half -ring  Thomas  (already  described)  and  the  Hodgen's 
(Fig.  25  B).  This  latter  is  essentially  a  suspension 
splint,  and  is  right  and  left.  The  angle  at  the  knee  may 
be  changed  by  bending  to  suit  the  requirements  of  in- 
dividual cases.  The  splint  is  shown  in  place  in  Figs. 
28  and  33.  The  suspension  cords  are  arranged  in  two 
sets;  the  proximal  cord  passes  upward  and  across  the 
patient  to  the  head  frame  on  the  opposite  side,  prevent- 
ing the  patient  from  sliding  and  the  splint  from  tilting. 
It  is  usually  better  balanced  if  the  distal  cords  are 
attached  one  approximately  opposite  the  malleoli  and 
the  other  just  proximal  to  the  knee.  The  main  cords 
should  be  attached  to  the  bridles  by  knots  that  cannot 
slip,  as  otherwise  the  splint  may  rotate.  Hodgen's 
sphnt  is  well  adapted  for  treatment  of  high  fractures 
of  the  femur  in  which  the  wounds  preclude  the  use  of 
the  Thomas.  It  is  more  apt  to  become  displaced  than 
the  Thomas  and  half-ring  splints,  in  which  the  ring 
helps  greatly  in  keeping  the  apparatus  in  position,  and 
when  in  use  much  attention  has  to  be  given  to  the  sling 
bands  at  the  proximal  end  to  keep  them  taut  and  in 
place. 

Either  the  Thomas  full  ring  or  half -ring  splints  may 
be  employed,  though  the  latter  will  be  found  to  be  the 
more  convenient.  The  bars  may  be  bent  at  the  knee  to 
suit  the  requirements  of  the  case.     Even  when  treating 


82      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

a  fracture  in  the  straight  position  of  the  limb,  as  in  Fig. 
29,  the  bars  should  be  bent  a  httle  (about  10°).  This 
angulation  aids  in  preventing  the  knee  from  sagging 
backward  and  in  maintaining  the  normal  anterior  bow- 
ing of  the  femur. 

The  Thomas  splints  possess  the  great  advantage  of 
intrinsically  maintaining  traction.  Ordinarily,  during 
treatment,  this  feature  is  not  made  use  of  traction  being 
applied  to  the  end  of  the  splint  in  order  to  prevent  the 
painful  counter-pressure  of  the  ring  and  for  other  rea- 
sons to  be  mentioned  later^ ;  but  if  it  should  be  necessary 
to  remove  the  patient  from  his  bed,  as,  for  instance,  for 
a  radiogram  when  no  portable  apparatus  is  available,  or 
for  operation  or  evacuation,  traction  may  be  kept  up  by 
simply  twisting  the  traction  straps.  The  Thomas 
splint,  therefore,  should  be  used  in  preference  to  any 
other  if  the  hospital  does  not  possess  a  portable  radio- 
graphic outfit  or  if  there  is  a  possibility  of  having  to 
evacuate  the  patient  before  consolidation  of  his  fracture. 

The  weight  for  suspension  should  just  balance  that 
of  the  limb  and  consequently  varies  with  the  case. 

In  some  instances  the  sound  limb  may  have  to  be  sus- 
pended in  abduction  in  order  to  maintain  abduction  in 
the  injured  one;  although,  ordinarily,  the  patient  can  be 
prevented  from  occupying  a  position  in  the  axis  of  the 
fractured  bone  by  a  band  about  his  body  fastened  to  the 
opposite  side  of  the  bed.  When  both  limbs  are  sus- 
pended, or  when  the  patient  has  to  be  raised  high  up 
to  give  access  to  wounds  of  the  buttock,  a  sling  made  of 
one  of  the  bands  for  the  Bradford  frame  should  be 

'Paert   04. 


DIAPHYSEAL  FRACTURES 


83 


passed  under  the  body.     A  stick  to  act  as  a  spreader 
is  fastened  to  each  end  of  the  sling,  and  cords  are  at- 


FiG.  28. — Method  of  treating  high  fractures  of  the  femur  with 
the  Hodgen's  splint  and  traction  by  the  Codavilla  (Stein- 
mann)  pin  or  Besley  tongs.  Abduction  is  obtained  by  plac- 
ing the  pulley  for  the  traction  cord  on  an  outrider,  and 
outward  rotation  by  tilting  the  splint. 

The  suspension  attachment  for  preventing  foot-drop  has  not 
been  drawn. 

(The  more  proximal  of  the  distal  suspension  cords  should  have 
been  attached  to  the  splint  at  the  proximal  side  of  the  knee. 


84      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

tached  to  the  stick  by  means  of  stout  hooks.  These 
cords  pass  over  pulleys  on  the  longitudinal  bars  to  coun- 
terpoises. The  patient,  by  pulling  on  the  latter  (which 
he  can  do  readily  himself)  can  be  suspended  clear  of 
the  bed  without  changing  the  relative  position  of  the 
limbs,  which,  since  they  are  counterpoised,  go  up  also 
(Fig.  30).  This  is  even  more  convenient  than  an 
apparatus  by  which  the  entire  patient  is  suspended, 
such  as  the  hammock  devised  by  Sinclair. 

Counterpoised  suspension  of  the  limb,  such  as  has 
been  described,  is  much  safer  and  more  comfortable  for 
the  patient  than  fixed  suspension.  It  is  well  to  suspend 
the  limb  to  a  trolley  (as  illustrated  in  the  cuts)  which, 
even  if  not  automatic,  is  easily  shifted  by  the  attendant 
when  the  patient  changes  his  position  in  the  bed. 

FooTDROP. — Support  of  some  kind  must  be  provided 
for  the  foot  in  treating  all  fractures  of  the  lower  extrem- 
ity. This  may  be  attached  to  the  splint  itself,  but  on 
account  of  the  variations  in  the  length  of  the  limb  due  to 
the  influence  of  traction  a  fixed  support  is  unsatisfac- 
tory. 

The  arrangement  shown  in  Figs.  29,  31  A  et  B,  and 
83  has  given  great  satisfaction.  It  consists  of  a  piece 
of  Canton  flannel,  or  several  thicknesses  of  gauze,  glued 
to  the  sole  of  the  foot  and  extending  beyond  the  ends 
of  the  toes.  From  this  end  a  cord  passes  upward  and 
cephalad  over  a  pulley  on  the  trolley  to  a  weight  of 
500  grammes.  This  holds  up  the  foot  without  fixing 
the  ankle,  which  the  patient  is  instructed  to  move  at 
frequent  intervals.     When  the  limb  is  to  be  put  in  a 


DIAPHYSEAL  FRACTURES 


85 


position  of  outward  rotation,  the  material  should  be 
glued  on  the  sole  obliquely,  so  that  the  cord  passes  up 
at  the  mesal  aspect  of  the  great  toe. 


Fig.  29. — Method  of  treating  high  fractures  of  the  femur  with 
the  half-ring  Thomas  splint.  Note  the  manner  of  obtaining 
abduction  and  flexion  at  the  hip,  also  the  attachment  to  pre- 
vent foot  drop.  The  traction  weight  is  not  applied  directly 
to  the  traction  straps  but  to  the  splint  and  consequently 
draws  the  latter  away  from  the  tuberosity  of  the  ischium. 
The  traction  straps  are  also  attached  to  the  splint  and  hold 
it  in  place. 

Traction. — One  of  the  most  important  and  vexing 
problems  is  the  best  manner  of  applying  traction. 
Broadly  speaking,  there  are  three  methods;  the  choice 


86      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

between  which  is  generally  limited  by  the  position  of 
the  fracture,  the  size  and  location  of  the  wounds  com- 
plicating it,  and  the  occurrence  of  other  wounds  or  frac- 
tures in  the  same  limb.  The  first  and  most  common 
method  is  to  attach  the  tractive  force  to  the  skin,  either 
by  applying  bands  of  Canton  flannel  or  of  gauze  by 
means  of  Sinclair's  or  Heussner's  glue,^  or,  better,  by 
using  the  well-known  moleskin  or  diachylon  plaster. 
Ordinary  adhesive  plaster  is  valueless  on  account  of  its 
slipping.  When  moleskin  plaster  is  used  the  end  of 
each  band  is  cut  into  three  strips — a  wide  central  piece 
which  is  applied  straight,  and  two  lateral  narrow  bands 
which  are  applied  in  opposing  spirals  avoiding  the  front 
and  back  of  the  knee.  The  bands  are  adjusted  from 
just  above  the  ankle  to  above  the  knee  if  possible.  Sin- 
clair prefers  gluing  the  strips  only  as  far  as  the  knee 
{vide  infra).  The  chief  disadvantages  of  this  method 
are :  that  the  knee  must  be  kept  in  an  extended  position, 
that  the  force  is  applied  mainly  through  the  ligaments 
of  the  knee  (which  become  stretched  and  thus  entail  a 
longer  convalescence),  and  that  irritation  of  the  skin 
(more  often  observed  in  infected  cases)  is  caused.  The 
bands  cannot  be  applied  solely  to  the  thigh  above  the 
knee  because  the  tractive  force  is  then  chiefly  trans- 
mitted by  the  skin  and  fascia  to  the  pelvis.  The  advan- 
tages of  bands  are  their  cheapness,  safety  and  ease  of 
application. 

The  second  method  is  to  make  traction  on  the  bones 
themselves.  This  is  accomplished  directly  by  Ranso- 
hoff' s  tongs  (Fig.  32)  or  the  Codavilla  pin  (Fig.  28) 
through  the  condyles  of  the  femur ;  and  indirectly  by  the 

'Page    42. 


DIAPHYSEAL  FRACTURES 


87 


Codavilla  pin  through  the  head  of  the  tibia  or  the  os 
calcis,  or  by  the  stirrup  of  Finochietto    (Fig.  31  C), 


Fig.  30. — Method  of  suspension  for  fractures  of  both  femora, 
showing  systems  of  applying  additional  suspension  at  the 
site  of  fracture  in  order  to  prevent  backward  angulation  of 
the  fragments,  and  also  a  method  of  counterpoising  the 
weight  of  the  body  of  these  cases. 

which  is  a  steel  band  passed  over  the  os  calcis  in  front 
of  the  tendo-achillis.  The  use  of  the  Codavilla  pin  or 
the  Ransohoff  tongs  through  the  condyles  of  the  femur 
is  the  most  perfect  of  all  methods  because  it  permits 
the  placing  of  the  limb  in  an  absolutely  correct  position 


88      GUN-SHOT  FRACTURES  OF  EXTREMITIES 


Fig.   31. — Four  methods  of  installing  traction  for  frac- 
ture of  the  leg: 

A.  With  a  gaiter.  (For  the  sake  of  clearness,  the  cot- 
ton dressing,  which  should  first  be  placed  about  the 
ankle,  has  been  omitted.) 

B.  With  traction  straps. 

C.  With  the  stirrup  of  Finochietto. 

D.  With  Sinclair's  skate. 


DIAPHYSEAL  FRACTURES  89 

and  acts  directly  upon  the  fragment  without  fixing  or 
injuring  the  knee.  With  it  a  weight  of  six  kilos  will 
produce  as  much  effect  as  fifteen  kilos  attached  by  the 
ordinary  adhesive  bands.  The  objection  to  it  is  the 
fear  of  infection  at  the  site  of  the  pin  or  tongs,  especially 
in  infected  fractures,  but  present  experience  seems  to 
prove  that  the  tongs  at  least  may  be  employed  with 
impunity.     The  Codavilla  pin  may  be  used  through 


Fig.  32. — RansohoiF's  tongs. 

the  head  of  the  tibia  with  equal  efficiency,  and  additional 
injury  to  the  femur  is  thus  avoided,  but  this  system  has 
the  disadvantage  of  stretching  the  ligaments  of  the 
knee.  By  using  the  Codavilla  pin  through  the  os  calcis, 
or  Finochietto's  stirrup,  no  advantage  is  gained  over 
the  adhesive  band  method  except  those  of  direct  action 
on  the  skeleton  and  avoidance  of  irritation  to  the  skin, 
but  one  of  them  may  be  employed  when  wounds  of  the 
leg  prevent  the  use  of  any  other  method. 

In  the  third  method  of  effecting  traction  the  knee  is 
strongly  flexed  and  the  tractive  force  is  applied  about 
the  latter  or  against  the  back  of  the  calf.  This  is  ordi- 
narily accomplished  in  two  ways.  By  Hennequin's 
method  (Fig.  33)  the  limb  is  surrounded  to  the  height 
of  the  middle  of  the  thigh  by  a  very  thick  dressing  of 
non-absorbent  cotton,  bandaged  on  very  snugly  with  a 


90      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

narrow  bandage.  The  knee  must  be  kept  in  flexion 
while  the  dressing  is  applied,  and  it  is  well  to  put  a  wet 
crinoline  or  very  thin  plaster  of  Paris  bandage  over  all 
to  keep  the  dressing  in  place.  A  figure  of  eight  hitch 
is  then  made  about  the  thigh  and  knee  by  means  of  a 
sheet  folded  several  times  so  as  to  make  a  band  1.50  m. 
(60  in.)  long  and  at  least  0.15  m.  (6  in.)  wide.  Henne- 
quin  cut  away  the  mattress  to  allow  a  place  for  the  foot, 
but  this  is  not  necessary  when  the  limb  is  slung  in  a  wide 
Hodgen's  splint.  Hennequin's  is  probably  the  best 
method  for  high  fractures  of  the  femur  when  the  Coda- 
villa  pin  cannot  be  used.  It  is  obvious  that  it  cannot  be 
employed  for  low  fractures  because  of  the  interference 
of  the  bandage  with  the  wound. 

The  alternative  manner  is  to  bandage  the  leg  to  a  well 
flexed  Hodgen's  splint  and  make  the  traction  on  the 
latter.  This  method  affords  access  to  wounds  in  the 
lower  part  of  the  thigh  for  dressing  purposes,  but  it  has 
a  great  disadvantage  in  that  it  is  exceedingly  difficult, 
when  it  is  adopted,  to  make  sufficient  traction  on  the 
splint  without  causing  unbearable  pressure  on  the  calf 
just  below  the  bend  of  the  knee,  particularly  in  the 
early  part  of  the  treatment  when  it  is  necessary  to  ex- 
ercise strong  traction  to  overcome  the  spasm  of  the 
muscles.  In  the  later  stages,  however,  when  only  slight 
traction  is  required  to  hold  what  has  already  been 
gained,  the  system  is  fairly  satisfactory.  It  will  be  re- 
ferred to  later  in  describing  the  treatment  of  low  frac- 
tures. When  strong  pressure  is  made  against  the  calf, 
the  head  of  the  fibula  should  be  padded  to  avoid  pres- 
sure upon  the  peroneal  nerve. 


DIAPHYSEAL  FRACTURES 


91 


In  the  case  of  coexistent  fractures  of  the  thigh  and 
leg  the  traction  has  to  be  divided,  because,  if  enough 
traction  to  reduce  the  fracture  of  the  femur  be  applied 
below  the  fracture  of  the  leg,  the  latter  will  be  over- 
stretched. If  the  fracture  of  the  leg  is  low  there  may  be 
room  enough  above  it  to  glue  bands  by  which  traction 
for  the  femur  can  be  made,  while  traction  for  the  frac- 
ture of  the  leg  may  be  effected  by  one  of  the  methods 
described  under  that  heading.      In  such  a  case  the 


Fig.   33. — Hennequin's  method  in   conjunction  with  Hodgen's 
spHnt  in  the  treatment  of  fracture  of  the  femur. 

weight  placed  on  the  femur  should  be  equivalent  to  the 
difference  between  the  weight  for  the  femur  proper  and 
the  weight  placed  on  the  leg,  the  limb  being  in  the 
straight  position.     For  example,  if  15  kilos  were  the 


92      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

weight  to  be  applied  for  the  fracture  of  the  femur  and  5 
kilos  for  that  of  the  leg,  10  kilos  should  be  placed  or 
the  straps  above  the  leg  fracture.  If  there  is  not 
enough  room  on  the  leg  for  glued  straps  and  there  are 
no  wounds  on  the  lower. part  of  the  thigh,  a  collar  of 
plaster  of  Paris  may  be  placed  around  the  latter,  care- 
fully modelled  about  the  condyles  of  the  femur,  to  which 
the  traction  for  the  femur  may  be  attached.  This  plas- 
ter should  be  modelled  directly  on  to  the  skin ;  if  a  band- 
age be  placed  under  it  it  is  apt  to  become  wrinkled  and 
cause  pressure  sores.  In  most  cases  of  double  fracture, 
it  is  better,  if  possible,  to  place  the  limb  on  a  splint 
bent  to  an  angle  of  135°  at  the  knee  (as  for  treatment 
of  fractures  of  the  leg — Fig.  35)  and  to  use  a  Codavilla 
pin  or  Ransohoff  tongs  for  the  traction  on  the  femur. 
The  amount  of  traction  for  fracture  of  the  thigh 
varies  with  the  musculature  of  the  member,  the  manner 
in  which  traction  is  made  (whether  directly  upon  the 
bone,  i.  e.  skeletal  traction,  or  on  the  skin) ,  and  the 
position  of  the  limb.  If  the  hip  and  knee  are  flexed  the 
muscles  which  produce  overlapping  are  relaxed,  and  not 
half  as  much  weight  as  that  required  in  the  straight  posi- 
tion of  the  limb  is  needed.  If  traction  is  made  by  glued 
or  adhesive  straps  fastened  to  the  leg  and  thigh  the  knee 
cannot  be  strongly  flexed  and  much  of  the  tractive  force 
is  transmitted  through  the  skin  and  fascia.  With  the 
knee  in  the  extended  position  a  weight  of  16  to  18  kilos 
is  usually  necessary  for  the  first  few  days,  while  with  the 
flexed  position  of  the  knee  and  with  skeletal  traction  by 
means  of  the  Codavilla  pin  or  Ransohoff  tongs,  a  weight 
of  8  to  9  kilos  is  generally  sufficient  and  may  be  too 


DIAPHYSEAL  FRACTURES  93 

much,  particularly  if  the  weight  of  the  limb  is  more  than 
counterbalanced  by  the  suspension  weights   (Fig.  28). 

As  has  already  been  said,  the  initial  traction  should 
be  sufficient  to  overstretch  the  muscle  in  the  first  few 
hours  or  at  least  in  the  first  day.  A  radiograph  should 
then  be  taken,  and  if  the  overlapping  has  entirely  dis- 
appeared the  weight  may  be  diminished  by  one-third. 
Two  or  three  days  later  another  radiograph  should  be 
taken,  when,  if  the  reduction  has  been  well  maintained, 
the  weight  may  be  gradually  decreased  to  that  just 
sufficient  to  maintain  it,  as  determined  by  frequent 
radiographic  examinations. 

Counter-traction  is  furnished  by  the  weight  of  the 
patient,  the  foot  of  the  bed  being  raised.  If  traction  is 
made  with  the  knee  extended,  the  foot  of  the  bed  will 
have  to  be  raised  about  30  cm.  (12  in.)  ;  while  if  made 
with  the  knee  flexed,  half  this  distance  will  be  found 
ample. 

The  patient's  head  and  shoulders  should  be  raised  if 
possible,  for  there  is  distinct  danger  of  pulmonary  com- 
plications from  hypostatic  congestion  in  feeble  and  sep- 
tic cases. 

When  traction  is  made  by  springs,  by  the  use  of  the 
Thomas  splint  on  the  Thomas  principle  (i.  e.  by  twist- 
ing the  traction  straps),  or  by  attaching  the  straps  to  a 
post  and  utilizing  the  weight  of  the  patient,  it  is  ex- 
tremely difficult,  if  not  impossible,  to  gauge  and  regu- 
late the  amount  of  traction  actually  employed;  the 
tendency  is  to  use  too  much  traction  over  too  long  a 
period  and  thereby  to  endanger  the  integrity  of  the 
ligaments  of  the  knee. 


94      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

Late  treatment: 

The  normal  length  of  time  for  consolidation  of  frac- 
tures of  the  femur  is  about  eight  weeks.  Exception- 
ally this  is  reduced,  especially  in  comminuted,  non-in- 
fected fractures,  such  as  those  caused  by  rifle  bullets  in 
which  the  fragments  of  bone  have  not  been  removed. 
In  these  cases  firm  union  may  be  accomplished  in  six 
weeks.  There  are  many  cases,  however,  in  which,  al- 
though consolidation  ma}"  occur  in  the  ordinary  period, 
the  union  is  weak  either  from  loss  of  substance  or  in- 
sufficient callus.  In  other  cases  union  is  delayed,  and, 
although  apparently  firm  to  the  examining  hands,  the 
bone  will  angulate  when  weight  is  put  upon  it.  This 
bending  may  be  very  gradual  and  increase  during  a 
period  of  several  months ;  it  is  more  frequently  observed 
after  secondary  operations  done  to  reduce  mal-union. 
In  such  instances  the  callus  may  be  very  large  and  give 
a  false  sense  of  security. 

Even  if  a  fracture  unites  normally  there  is  danger 
of  the  patient's  falling  and  re-breaking  it.  Refrac- 
tures  of  the  femur  have  been  so  common  as  to  make  the 
French  Service  de  Sante  prohibit  the  use  of  crutches. 

To  avoid  such  accidents  and  deformations  and  to 
permit  the  patient  to  use  his  limb  at  the  earliest  possible 
moment,  an  ambulatory  splint  should  be  fitted  to  all 
cases.  The  most  satisfactory  is  the  Thomas  knee  splint. 
In  the  British  army  the  fitting  of  these  splints  is  termed 
"calipering,"  and  all  fractures  of  the  femur  are  "cali- 
pered"  before  being  sent  home. 

The  Thomas  splint  used  for  this  purpose  differs  from 
that  employed  for  transportation  and  treatment  in  re- 


DIAPHYSEAL  FRACTURES  95 

gard  to  the  size  of  the  ring,  which  is  much  smaller.  The 
ring  must  fit  closely  to  the  thigh  so  that  the  weight, 
when  the  patient  is  walking,  is  borne  on  the  tuberosity 
of  the  ischium.  Eleven  sizes  of  the  splint  are  neces- 
sary to  fit  all  cases,  the  internal  circumference  of  the 
bare  ring  varying  by  inches  from  16  in.  to  26  in.  The 
size  for  the  average  thigh  has  an  internal  circumfer- 
ence of  21  in.,  and  ten  splints  of  this  dimension  will  be 
used  as  against  nine  each  of  20  in.  or  22  in.,  seven  each 
of  19  in.  or  23  in.,  five  each  of  18  in.  or  24  in.,  three 
each  of  17  in.,  or  25  in.,  and  one  each  of  16  in.  or  26  in. 
In  measuring  for  a  splint  the  circumference  of  tlie  thigh 
is  taken  at  the  gluteal  fold  and  two  inches  added  to  it, 
one  for  the  obliquity  of  the  ring  and  the  other  for  the 
thickness  of  the  padding.  The  latter  should  be  four 
inches  in  circumference  at  the  inner  side  of  the  ring  and 
taken  to  nothing  at  the  outer.  The  bars  of  the  sphnt 
are  made  of  three-eighths  inch  iron  rod,  and  the  inner 
bar  is  one-third  of  the  internal  circumference  of  the 
ring  shorter  than  the  outer.  To  caliper  a  patient  the 
ring  is  slipped  over  the  leg  and  forced  firmly  up  against 
the  ischium,  and  a  mark  is  made  on  one  of  the  bars  at 
the  level  of  the  sole  of  the  bare  foot.  The  bars  are 
then  cut  off  2l/>  inches  below  this  mark.  The  patient's 
boot  having  been  re-soled  and  heavily  re-heeled,  the 
terminal  ll/)  inches  of  the  bars  are  bent  inward  at  a 
right  angle  and  fastened  into  holes  bored  into  the  heel, 
that  on  the  inner  side  of  the  heel  being  1  inch  behind 
the  one  on  the  outer  side  in  order  to  provide  for  the 
outward  rotation  of  the  foot. 

If  angulation  has  occurred  during  the  late  treatment 


96      GUN-SHOT  FRACTURES  OF  EXTREMITIES 

of  a  fractured  femur  and  the  callus  is  not  absolutely 
firm,  the  Delbet  splint  will  be  found  to  be  of  distinct 
value.  This  splint  or  apparatus  (Fig.  34)  consists  of 
three  metal  uprights,  two  of  which  are  welded  to  a 
pelvic  ring  resembling  in  principle  that  of  the  Thomas 
splint  but  incomplete,  and  the  other  attached  to  the 
ends  of  the  ring  segment  by  means  of  a  strap.  Each 
upright  consists  of  a  rod  telescoping  into  a  tube  and 


Fig.  34. — Delbet's  apparatus  for  ambula- 
tory treatment  of  fractures  of  the  femur. 
(By  the  courtesy  of  M.  le  Medecin-Major 
R.  Leriche). 

fitted  with  a  spiral  spring  and  suitable  stops  for  regulat- 
ing the  tension  of  the  spring  or  blocking  it.  The  lower 
ends  of  the  rods  are  embedded  into  a  plaster  collar  about 


DIAPHYSEAL  FRACTURES  97 

the  lower  part  of  the  thigh  and  bearing  on  the  femoral 
condyles.  This  collar  is  connected,  as  shown  in  the 
illustration,  by  two  lateral  splints,  with  two  other  col- 
lars, one  just  at  and  below  the  tuberosity  of  the  tibia, 
the  other  just  above  the  ankle  and  bearing  on  the  mal- 
leoli. The  apparatus  is  essentially  an  ambulatory  one, 
and  Delbet's  patients  are  up  and  walking  within  a  few 
days  from  reception  of  their  injury.  It  is  used  more 
commonly  for  late  treatment,  and  the  tendency  to  angu- 
lation (which  is  almost  always  outward)  can  be  over- 
come by  increasing  the  force  of  the  spring  on  the  adduc- 
tor side  of  the  tliigh. 

In  cases  in  which  the  callus  is  soft,  either  the  calipers 
or  the  Delbet  apparatus  may  have  to  be  worn  for 
months. 

Mechanical  treatment  of  special  fractures  of  the  femur: 

Fracture  of  the  Neck  of  the  Femur. — These 
fractures  practically  always  involve  the  articulation, 
and  will  be  considered  later  with  fractures  of  the  hip 
joint. 

Fracture  of  the  Upper  Third  of  the  Femur. — 
Such  cases  are  not  infrequently  complicated  by  injury 
to  the  pelvis.  The  wounds  of  the  soft  parts  are  large, 
or  have  to  be  made  so  in  order  to  explore  the  fracture 
and  to  effect  drainage;  they  are  often  situated  posteri- 
orly, which  makes  them  difficult  to  dress,  and  it  is  fre- 
quently impossible  to  use  the  Thomas  splint  because 
of  them.  Antero-posterior  wounds  being  in  the  region 
of  the  femoral  vessels  and  of  the  anterior  crural  and 
sciatic  nerves,  large  drainage  tubes   should  never  be 


98      GUX-SHOT  FRACTURES  OF  EXTREMITIES 

used  in  such  cases.  If  additional  drainage  is  necessary 
the  incision  should  be  made  behind  the  great  trochanter, 
well  to  the  outer  side  of  the  sciatic  nerve.  The  position 
assumed  by  the  upper  fragment  is  that  of  marked  ab- 
duction, rotation  out  and  flexion,  the  flexion  being  more 
accentuated  when  the  lesser  trochanter  remains  attached 
to  it.  To  bring  the  lower  fragment  effectively  into  line 
the  limb  should  be  suspended  in  marked  abduction  and 
rotation  out,  with  the  knee  flexed.  The  best  way  of 
accomplishing  this  is  to  use  the  Codavilla  pin  or  the 
Ransohoff  tongs.  In  these  cases  the  best  arrangement 
of  the  suspension  frame  is  that  shown  in  Fig.  28.  The 
necessary  position  for  the  limb  is  best  grasped  by  flex- 
ing one's  own  hip  and  knee  and  rotating  the  limb  out- 
ward, when  it  will  be  seen  that  the  leg  assumes  a  posi- 
tion midway  between  the  antero-posterior  and  trans- 
verse planes  of  the  bodj^  and  that  when  the  limb  is 
well  abducted  the  foot  hes  in  the  median  plane  of  the 
body.  To  maintain  the  splint  and  limb  in  this  position 
of  outward  rotation,  the  bridles  (i.  e.,  the  cords  fixed 
directly  to  the  splint  and  to  the  bights  of  which  the  sus- 
pending cords,  are  tied)  must  be  arranged  so  that  the 
parts  attached  to  the  inner  bar  of  the  splint  are  much 
shorter  than  those  attached  to  the  outer.  It  may  even 
be  necessary  to  fix  a  guy  line  to  the  foot  and  pass  it  over 
a  pulley  (fastened  to  the  opposite  longitudinal  bar)  to 
a  sufficient  weight.  The  weight  for  skeletal  traction  at 
the  outset  should  be  about  8  kilos  (18  lbs.). 

When  the  pin  or  tongs  cannot  be  used  the  Hennequin 
method  may  be  employed  with  the  limb  in  the  same  posi- 
tion and  a  commencing  weight  of  10  kilos    (22  lbs.) 


DIAPHYSEAL  FRACTURES  99 

(Fig.  33) .  If,  for  any  reason,  neither  the  Coda  villa  pin 
nor  the  Hennequin  method  can  be  used,  the  limb  is  put 
on  a  straightened  Hodgens  splint  (traction  being  made 
by  straps  passing  well  above  the  knee  or  by  the  Fino- 
chietto  stirrup)  and  placed  in  the  position  of  abduction, 
rotation  out  and  flexion  at  the  hip,  the  knee  of  course 
being  extended  ( Fig.  29 ) .  With  this  arrangement  the 
initial  weight  must  be  at  least  14  to  18  kilos  (30  to  40 
lbs.),  because  the  hamstrings  must  be  stretched  and  the 
weight  of  the  limb  overcome. 

When  a  straight  splint  is  used  the  other  limb  may 
have  to  be  suspended  in  like  abduction  in  order  to  main- 
tain abduction  in  the  injured  one.  This  is  seldom  nec- 
essary, however,  when  the  flexed  position  of  the  knee 
is  employed. 

With  all  the  above  methods  the  foot  of  the  bed  is  ele- 
vated and  the  patient's  head  and  shoulders  should  be 
raised  on  pillows. 

Fracture  of  the  Middle  of  the  Femur. — In  these 
the  wounds  are  at  the  middle  of  the  thigh  and  do  not 
interfere  materially  with  the  use  of  any  method  except 
the  Hennequin.  The  position  assumed  by  the  upper 
fragment  is  abduction  if  the  fracture  is  above  the  ad- 
ductor longus  insertion;  otherwise  it  is  nearly  straight, 
moderately  flexed  and  rotated  out.  These  cases  are 
the  easiest  to  treat  because  the  position  of  the  fragments 
is  controlled  by  the  lateral  pressure  of  the  muscles  when 
strong  traction  is  made. 

As  has  been  emphasized  by  Sinclair,  due  regard  must 
be  given,  in  treating  all  fractures  of  the  shaft,  to  repro- 
ducing the  normal  anterior  curvature  of  the  femur.    If 


100     GUX-SHOT  FRACTURES  OF  EXTREMITIES 

traction  is  applied  in  the  axis  of  the  bone,  the  best  re- 
sult that  can  be  hoped  for  is  a  perfectly  straight  bone; 
generally,  however,  a  position  of  backward  curvature 
will  be  obtained.  This  is  particularly  true  in  fractures 
below  the  middle  of  the  shaft.  The  best  way  to  over- 
come the  tendency  of  the  fragments  to  backward  sag- 
ging, is  to  apply  the  tractive  force  in  a  line  below  the 
axis  of  the  femur  and  to  place  a  support  behind  the 
fragments  so  that  the  pull  will  be  made  against  the  sup- 
port, thus  forcing  the  fragments  forward.  This  is  ac- 
complished by  means  of  a  bent  splint,  the  bend  being 
about  4  cm.  above  the  knee  joint.  The  angle  varies 
slightly  with  the  case,  but  should  be  about  160°.  A 
Thomas  splint  will  be  found  the  most  satisfactory.  The 
ordinary  muslin  or  flannel  slings  are  used,  but  they 
should  be  doubled  behind  (particularly  just  below  the 
point  of  fracture)  so  as  to  afford  an  unyielding  sup- 
port. The  limb,  when  suspended  in  such  a  splint,  is  in 
a  position  of  flexion  at  the  hip  and  moderate  flexion  at 
the  knee.  Traction  may  be  made  in  the  axis  of  the  leg 
by  glued  bands,  in  which  case  the  splint  does  not  have 
to  be  bent  so  much  as  when  the  tongs  are  used  directly 
upon  the  femur.  In  the  latter  case  the  axis  of  traction 
must  be  higher  in  order  to  clear  the  leg,  which  in  turn 
necessitates  a  position  of  greater  flexion  of  the  femu.r. 

It  is  obvious  that  when  traction  is  thus  made  against 
a  supporting  band  attached  to  the  splint,  the  fraction 
should  not  be  applied  to  the  end  of  the  splint  but  rather 
directly  to  the  limb,  and  that  the  splint  should  be  held 
against  the  limb.  The  method  of  suspension  should 
therefore  be  that  shown  for  the  Hodgens  sphnt  (Figs. 


DIAPHYSEAL  FRACTURES  101 

33  et  35).  A  supplementary  sling,  attached  by  a  cord 
to  a  weight,  may  also  be  used  to  correct  the  position  of 
the  fragments  (Fig.  30). 

The  Thomas  splint  thus  used  is  merely  a  cradle  for 
suspension,  but  should  the  patient  have  to  be  moved 
from  his  bed  it  is  only  necessary  to  attach  the  traction 
straps  or  cords  to  the  end  of  the  splint  to  bring  the 
Thomas  principle  into  play. 

Fracture  of  the  Lower  Third  of  the  Femur. — 
In  very  low  fractures  of  the  shaft,  if.  the  method  just 
described  does  not  suffice  to  overcome  the  strong  tend- 
ency of  the  lower  fragment  to  become  flexed  backward 
by  the  pull  of  the  gastrocnemius,  the  Ransohoff  tongs 
have  been  used  successfully  in  the  following  way.  They 
are  applied,  as  usual,  to  the  upper  part  of  the  lower 
epiphysis,  but  instead  of  making  traction  below,  the 
traction  is  made  above  the  axis  of  the  femur,  thus  act- 
ually tilting  the  fragment  upward.  Care  should  be 
taken  to  obtain  the  elongation  necessary  before  raising 
the  axis  of  traction,  as  otherwise  the  upper  end  of  the 
lower  fragment  may  engage  behind  the  lower  end  of 
the  upper  and  reduction  be  impossible. 

If  the  tongs  cannot  be  used  on  account  of  the  prox- 
imity of  infected  wounds,  and  complete  reduction  of 
the  backward  angulation  has  not  been  obtained  by  the 
other  method,  the  following  procedure  should  be  tried. 
While  the  union  is  still  soft,  the  splint  should  be  flexed 
to  a  full  right  angle  and  the  leg  bent  to  suit.  The  knee 
will  have  been  somewhat  stiffened  by  the  long  traction 
and  the  bending  will  therefore  take  place  at  the  frac- 
ture.    Traction  is  then  made  on  the  splint  at  the  knee 


102     GUN-SHOT  FRACTURES  OF  EXTREMITIES 

and  transmitted  to  the  back  of  the  calf.  If  strong  trac- 
tion has  been  used  from  the  beginning  of  treatment  the 
muscles  will  have  been  stretched  so  that  only  moderate 
force  will  be  necessary.  This  method  has  given  satis- 
factory results  during  the  last  two  years. 

TIBIA  AND  FIBULA 

Fractures  of  the  fibula  alone  are  of  little  consequence, 
as  the  tibia  acts  as  an  efficient  support  for  the  broken 
bone.  Fractures  of  the  tibia  alone  are  splinted  by  the 
fibula,  which  prevents  over-riding  to  any  great  extent, 
though  it  cannot  obviate  (especially  in  cases  of  loss  of 
substance)  a  tendency  to  incurvation.  Fractures  of 
both  bones  tend  to  overlap  and  also  be  interlock  in  bad 
positions,  and  are  often  difficult  to  reduce;  moreover, 
repair  in  the  leg  seems  more  indolent  than  elsewhere 
in  the  body,  and  these  fractures  sometimes  unite  very 
slowly  and  imperfectly.  The  lack  of  soft  parts  over 
the  tibia  possibly  accounts  for  some  of  such  cases  of 
delayed  union,  sluggishly  granulating  wounds  and  dis- 
agreeable scars. 

Transport: 

The  problem  of  transport  is  simple.  The  fragments 
are  easily  fixed  by  any  splint,  but  it  is  advisable  to  use 
the  Thomas  on  account  of  the  traction  it  affords,  which 
does  much  to  prevent  laceration  of  the  muscles,  tendon 
sheaths  and  skin  as  well  as  to  obviate  over-riding  and 
interlocking.  It  is  applied  in  the  same  manner  as  for 
fractures  of  the  femur,  except  that  the  leg  should  be 
well  bandaged  into  the  splint.    If  the  fracture  is  in  the 


DIAPHYSEAL  FRACTURES  103 

region  of  the  ankle  the  boot  should  be  removed  and 
the  anklet  placed  over  the  dressing.  In  these  cases  care 
should  be  taken  to  support  the  foot,  and  for  this  pur- 
pose the  Cabot  leg  splint  may  be  tied  to  the  Thomas 
if  a  foot  rest  is  not  at  hand. 

At  the  initial  operation  the  fracture  should  be  re- 
duced if  possible,  as  these  fractures,  above  all,  need 
direct  instrumental  intervention  to  effect  proper  re- 
duction ;  if  done  at  once  a  secondary  operation  will  often 
be  avoided.  All  projecting  fragments  which  might 
produce  pressure  necrosis  of  the  overlying  skin  should 
be  carefully  pushed  back  in  place;  if  it  is  not  possible 
to  do  this  it  is  better  to  remove  them. 

If  the  fracture  has  already  become  infected,  however, 
an  operative  reduction  should  not  be  attempted,  as  very 
disagreeable  suppuration  of  the  muscle  planes  and  ten- 
don sheaths  is  apt  to  be  provoked  on  the  breaking  down 
of  the  barriers  to  infection  which  have  been  formed. 

Primary  and  delayed  primary  suture  have  been  quite 
successful  in  treating  fractures  of  the  leg.  On  account 
of  the  better  conservation  of  the  tendons,  primary  su- 
ture is  preferable  to  secondary  suture,  especially  in 
low  fractures. 

Mechanical  treatment: 

All  wounds  and  fractures  of  the  leg  repair  far  more 
quickly  if  the  limb  be  suspended.  Traction  is  neces- 
sary in  fractures  of  both  bones. 

The  best  method  is  to  suspend  the  limb  in  a  Hodgens 
or  Thomas  splint  bent  to  135°  (Fig.  35).  The  center 
of   suspension    should    be    below   the    knee.      A   cord 


104.     GUN-SHOT  FRACTURES  OF  EXTREMITIES 

attached  by  a  bridle  to  the  thigh  part  of  the  sphnt 
passes  back  to  a  pulley  on  the  head  frame  on  the  oppo- 
site side  from  the  fracture  and  provides  counter  exten- 
sion. Traction  is  made  in  a  straight  line  to  the  foot 
frame.  Frome  6  to  7  kilos  (13  to  15  lbs.)  are  sufficient 
to  commence  with  for  fractures  of  both  bones ;  half  this 
amount  should  be  used  for  fractures  of  the  tibia  alone. 
The  weight  must  be  rapidly  diminished.  If  there  is  no 
tendency  toward  overlapping  half  the  amount,  or  less, 
is  enough.  The  effect  of  the  traction  should  be  verified 
by  X-rays. 

In  high  fractures  the  weight  may  be  attached  to  glued 
straps  (Fig.  31  B).  In  low  fractures  the  Sinclair  skate 
(Fig.  31  D)  or  the  Finochietto  stirrup  (Fig.  31  C) 
should  be  used.  The  gaiter  method  (Fig.  31  A)  is  not 
suitable  for  strong,  continued  traction  even  when  a 
heavy  dressing  is  placed  beneath,  for  in  spite  of  every 
care  pressure  sores  will  form  at  the  dorsum  of  the  foot 
and  at  the  attachment  of  the  tendo-achillis  when  it  is 
employed.  It  is,  however,  valuable  as  a  supplementary 
traction  and  can  be  used  in  conjunction  with  glued 
straps.  The  Sinclair  skate  consists  of  a  half -inch  board 
longer  than  the  foot  and  9  cm.  wide.  In  this  a  central 
slot  is  cut  (as  clearly  shown  in  the  illustration)  in  which 
slides  a  bolt  with  a  winged  nut.  The  bolt  passes 
through  a  hole  in  the  center  of  a  piece  of  strap  steel 
15  cm.  long.  This  steel  crosspiece  serves  for  the  attach- 
ment of  the  traction  cords,  and,  resting  on  and  across 
the  bars  of  the  splint,  also  acts  as  a  regulator  of  the 
position  of  the  foot.  When  it  is  clamped  toward  the 
heel  the  traction  dorsiflexes  the  ankle,  and  conversely. 


DIAPHYSEAL  FRACTURES  105 

when  clamped  toward  the  toes  plantar  flexion  is  pro- 
duced. Moreover,  as  the  bar  rotates  on  the  bolt,  the 
rotation  of  the  foot  may  be  controlled.  Eight  or  ten 
notches,  1  cm.  apart,  are  cut  on  each  side  of  the  board 
and  serve  to  prevent  the  slipping  of  the  lacing  cord 


Fig.  35. — Method  of  treating  fractures  of  the  tibia  and  fibula 
by  suspension  and  traction.  The  limb  is  suspended  in  a 
Hodgens  splint  bent  to  an  angle  of  about  135°.  Traction  in 
this  case  is  made  (as  shown)  with  straps  glued  on  to  the  leg. 

which  fastens  it  to  the  glued  straps.  The  straps  are 
made  beforehand  of  Canton  flannel  or  tape  with  small 
curtain  rings  sewed  to  their  ends.  They  are  glued  to  the 
sides  of  the  foot  as  shown  in  the  illustration  and  must 
not  overlap  on  the  dorsum.  The  board  is  padded  so  as 
to  conform  to  the  sole  of  the  foot  and  is  laced  on  either 


106     GUN-SHOT  FRACTURES  OF  EXTREMITIES 

by  a  continuous  cord  or  by  separate  cords  for  each  pair 
of  opposed  rings. 

Another  form  of  skate  devised  by  Sinclair  consists  of 
a  plaster  sole  lined  with  saddler's  felt,  which  is  accu- 
rately modelled  to  the  sole  of  the  foot  and  glued  to 
same.  A  piece  of  strap  iron  bent  to  a  shape  resembling 
a  right-angled  letter  omega  is  embedded  by  its  feet 
into  the  bottom  of  the  plaster  sole.  The  free  portion  of 
the  omega  iron  has  a  slot  in  it  corresponding  to  and  serv- 
ing the  same  purpose  as  the  slot  in  the  wooden  skate. 
The  plaster  skate  is  used  when  wounds  of  the  foot  pre- 
vent the  use  of  the  wooden  one. 

Obviously,  fractures  of  the  tibia  and  fibula  may  be 
treated  in  a  Thomas  splint,  but  being  straight  it  is  not 
so  satisfactory.  If  the  patient  is  to  be  evacuated,  how- 
ever, the  Thomas  splint  should  be  used  in  order  that 
traction  may  be  kept  up  during  transport. 

Ambulatory  treatment  of  fractures  of  tibia  and  fibula: 

As  has  already  been  stated,  delayed  union  is  not  un- 
common in  fractures  of  the  tibia  and  fibula.  In  such 
cases  it  is  important  that  the  function  of  the  leg  should 


Fig.  36. — Delbet's  ambulatory  splint  for 
fracture  of  the  tibia  and  fibula.  (By  the 
courtesy  of  M.  le  Medecin-Major  R.  Ler- 
iche.) 


DIAPHYSEAL  FRACTURES 


107 


be  resumed,  as  the  increased  circulation  and  trauma- 
tism at  the  ends  of  the  bones  caused  thereby  greatly 
aids  in  hastening  union.     A  certain  amount  of  weight 


/I 


■:SS:^ 


m 


^E 


C 
D 


es<" 


Jll 


=^ 


65 


65 


Fig.  37. — Method  of  cutting  strips  of  crino- 
line to  make  the  plaster  bands  for  Delbet's 
ambulatory  splint  for  fracture  of  the  tibia 
and  fibula. 

A.  Upper  band. 

B.  Lower  malleolar  band. 

C.  and  D.  Lateral  bands  with  folds  10 
cm.  long  at  inferior  extremity. 

E.  Lower  band  for  the  malleoli  with  notch 
cut  in  heel  piece  for  heel.  (By  the  cour- 
tesy for  M.  le  Medecin-Major  R.  Leriche). 

should  be  borne  on  the  leg,  but  the  fracture  must  be  sup- 
ported and  angulation  prevented.  The  Delbet  leg 
splint,  the  tibia  and  head  of  the  fibula  above  and  against 


108     GUN-SHOT  FRACTURES  OF  EXTREMITIES 

the  malleoli  below,  thus  preserving  the  length  of  the 
leg.  To  be  successful  the  splint  must  be  skillfully 
applied.  In  such  cases  patients  with  simple  fractures 
can  walk  in  three  or  four  days  after  reception  of  their 
injury.  The  plaster  is  put  directly  on  the  vaselined  or 
talcum-powdered  skin.  Recent  fractures  are  reduced 
by  attaching  a  weight  of  25  kilos  to  the  foot,  and  the 
splint  is  applied  while  the  traction  is  still  attached. 


CHAPTER  VI 

FRACTURES  AND  WOUNDS  OF  JOINTS 

General: 

Experience  during  this  war  has  unequivocally  proved 
that  the  ideas  formerly  prevalent  concerning  the  ex- 
treme susceptibility  to  infection  of  the  synovia  were 
erroneous.  At  the  present  time  most  of  the  wounds 
of  joints  are  being  closed  successfully,  and  it  has  been 
found  that  if  they  suppurate  the  infection  is,  as  a  rule, 
confined  to  the  periarticular  tissues  or  at  least  com- 
mences there.  In  proof  of  this  assertion  it  is  frequently 
observed  that  part  of  a  joint  may  be  infected  while  the 
rest  of  it,  although  continuous  with  the  infected  portion, 
remains  free. 

It  has  also  been  remarked  that  the  presence  of  for- 
eign bodies  or  materials  in  joints  brings  about  infec- 
tion and  encourages  its  progress.  This  is  not  only  true 
of  carriers  of  infection,  such  as  shell  fragments  and 
clothing,  but  also  of  objects  considered  surgically  clean, 
such  as  drainage  tubes.  In  support  of  this  it  has  been 
found  that  cases  of  suppurative  synovitis,  which,  by  the 
older  treatment  of  drainage  by  tube,  would  have  ended 
in  the  loss  of  the  joint,  if  treated  by  simple,  free  inci- 
sions and  a  mild  irrigation  to  wash  out  the  pus  recover 
rapidly  and  satisfactorily. 

The  rulei^  for  treatment  of  wounds  of  the  joints  are, 
therefore,  exceedingly  simple.     Recent,  contaminated 

109 


110     GUN-SHOT  FRACTURES  OF  EXTREMITIES 

wounds  should  be  treated  as  alreadj^  described  for 
wounds  of  the  soft  parts  accompanying  fractures.  All 
foreign  bodies  should  be  removed,  contaminated  and  in- 
jured synovia  cut  away,  especial  attention  given  to  re- 
moving small,  loose  fragments  and  all  infected  bone, 
and  perfect  hasmostasis  made.  The  synovia  shoidd 
then  be  closed  by  cat-gut  sutures,  and  wounds  of  the 
periarticular  structures  either  closed  by  primary  or  left 
for  delayed  primary  or  secondary  suture.  When  there 
is  injury  to  the  bone  communicating  with  the  exterior 
through  the  joint,  it  is  well  to  expose  the  bone  wound 
by  an  incision  over  it  so  that  in  case  of  infection  the 
bone  will  drain  directly  to  the  surface  and  not  through 
the  joint.  The  worst  and  most  persistent  suppurations 
of  the  joints  are  those  caused  by  infection  of  the  bones 
forming  them,  so  that  every  precaution  should  be  taken 
in  the  way  of  removing  all  causes  of  infection  in  the 
bone  wounds  and  isolating  them  from  the  joint  cavity. 

In  treating  joints  already  infected  free  incisions  so 
planned  as  to  not  only  drain  the  joint  but,  above  all,  the 
wounds  of  the  bones,  should  be  made.  Xo  drains  of  any 
sort  should  be  used,  but  the  wounds  leading  into  the  joint 
should  be  kept  open  until  all  drainage  from  it  ceases. 
At  the  time  of  operation  the  joint  may  be  irrigated  out. 
The  value  of  subsequent  irrigation  is  questionable.  If 
made,  the  greatest  gentleness  should  be  observed  so  as 
not  to  injure  the  sjnovia.  It  is  probable  that  normal 
saline  or  isotonic  sodium  bicarbonate  solution  is  as 
good  as  any  fluid  for  irrigating  purposes. 

The  indications  for  radical  operative  procedures  on 
the  bones,  such  as  excision,  vary  with  the  different  joints 


FRACTURES  AND  WOUNDS  OF  JOINTS        111 

and  will  be  considered  under  the  heading  of  each. 
Post-operative  treatment  of  wounds  of  the  joints  de- 
pends largely  upon  the  extent  of  injury  to  their  archi- 
tecture and  also  upon  their  normal  functions;  for  the 
elbow,  for  example,  free  movement  may  be  desirable 
at  the  expense  of  strength,  while  stability  at  the  cost  of 
mobility  is  usually  preferable  for  the  knee.  These  ques- 
tions will  be  discussed  later,  in  detail,  for  each  joint.  A 
general  line  of  treatment  may,  however,  be  mapped  out 
for  wounds  implicating  the  synovia  alone  or  accom- 
panied by  slight  or  moderate  injury  to  the  bones. 
Early  mobilization  is  beneficial  in  these  cases,  as  ha^ 
been  demonstrated  by  Wilhelm,  who  commences  mobili- 
zation on  the  day  following  operation  even  when  mild 
infection  is  present.  The  passive  motion  carried  out 
for  the  first  two  or  three  days  is  at  once  followed  by 
active  motion,  and  patients  with  wounds  of  the  knee 
or  ankle  are  walking  by  the  third  or  fourth  day.  When 
begun  early  and  carried  out  consistently,  motion  and 
use  of  a  joint  are  not  painful.  If  it  is  infected  it  is  of 
course  left  open,  but  without  drains;  Wilhelm  claims 
that  drainage  is  improved  by  the  motion.  The  func- 
tional results  of  his  method  are  far  better  and  more 
rapid  than  those  obtained  by  the  old  fixation  treat- 
ment. 

SHOULDER 

In  a  large  number  of  fractures  of  the  shoulder  all 
three  bones — humerus,  scapula  and  clavicle — are  in- 
volved. Wounds  at  the  point  of  the  shoulder  often  pre- 
sent loss  of  substance  with  a  wide  laying  open  of  the 


112     GUN-SHOT  FRACTURES  OF  EXTREMITIES 

joint.  In  such  cases  the  origin  of  the  deltoid  is  fre- 
quently destroyed.  Wounds  involving  chiefly  the  head 
of  the  humerus  are  deep,  as  the  joint  is  here  surrounded 
by  heavy  muscles;  they  are  consequently  prone  to  an- 
aerobic infection. 

The  deltoid  muscle  is  the  principle  abductor  of  the 
arm,  as  well  as  the  one  which  supports  its  weight.  If  it 
ceases  to  act  the  humerus  descends  and  the  motions  of 
the  shoulder  are  lost  or  much  weakened.  Great  care 
should  be  taken  to  preserve  it  and  its  nerve,  the  circum- 
flex, which  passes  backward  around  the  neck  of  the 
humerus  in  a  line  5  to  6  cms.  below  the  border  of  the 
acromion  process. 

Transport: 

Traction  is  not  indicated,  and  the  sling  and  body 
bandage  method  is  therefore  the  best  for  fixation  for 
transport  from  the  field.  For  transport  after  operation 
one  of  the  methods  described  for  ambulatory  treatment 
(page  106)  may  be  used.  These  cases,  however,  should 
not  be  transported  until  convalescent: 

Operative  treatment: 

Punctate  bullet  wounds  should  not  be  operated  on. 
All  others  should  receive  surgical  treatment  as  early  as 
possible. 

If  sufficient  access  for  exploration  is  not  afforded  by 
enlarging  the  wounds,  or  if  they  cannot  be  enlarged  on 
account  of  their  position,  the  incision  for  typical  resec- 
tion should  be  made  at  the  anterior  border  of  the  deltoid 
and  the  joint  opened  at  the  outer  side  of  the  bicipital 


FRACTURES  AND  WOUNDS  OF  JOINTS        113 

groove  and  tendon.  After  this  approach  counter-drain- 
age is  made,  if  necessary,  posteriorly  above  the  circum- 
flex nerve.  The  drains  should  be  introduced  only  as 
far  as  the  joint  and  should  not  enter  it. 

All  missiles  lodged  in  the  humeral  epiphysis,  even  if 
the  wounds  do  not  implicate  the  joint,  should  be  re- 
moved— with  the  possible  exception  of  rifle  balls,  which 
are  usually  innocuous.  A  diligent  search  for  bits  of 
clothing  must  be  made,  as,  if  such  foreign  bodies  are 
not  removed  the  joint  is  apt  to  become  involved  in  the 
subsequent  infection  of  the  bone. 

In  cases  of  fracture  typical  resection  should  be 
avoided  except  when  the  head  of  the  humerus  is  smashed 
into  small  pieces.  Ordinarily  the  surgeon  must  be  con- 
tented with  the  removal  of  spicular  and  irregular  por- 
tions of  bone  which  would  be  likely  to  interfere  with  the 
function  of  the  joint.  The  cartilage  should  not  be  re- 
moved unless  the  joint  is  already  infected. 

In  early  operations,  when  there  is  every  reason  to  ex- 
pect an  aseptic  evolution  of  the  wound,  the  latter  may 
be  loosely  closed;  but,  as  a  rule,  it  is  better  to  simply 
close  the  synovia  and  leave  the  wound  of  the  superficial 
parts  for  delayed  primary  or  secondary  suture.  In  re- 
cent wounds,  in  which  infection  is  already  established — 
particularly  in  fractures  extending  into  the  diaphysis 
of  the  humerus  with  much  comminution — the  surgeon 
should,  on  account  of  the  great  danger  to  life  and  limb, 
be  less  conservative  of  bone  and  work  for  an  absolutely 
free  drainage.  Large  openings  should  be  made,  a  free 
sub-periosteal  resection  done,  all  the  cartilage  of  the 
articulation  removed,  and  the  wounds  left  open. 


1 1 4     GUN-SHOT  FRA  CTURES  OF  EXTREMITIES 

In  later,  suppurative  cases,  where  the  danger  of  an 
explosive  infection  is  past  but  in  which  abscesses  form 
from  extension  along  the  muscles,  the  surgeon  should 
limit  himself  to  free  drainage  of  these  extensions  and 
not  resect. 

Mechanical  treatment: 

If  the  after-treatment  is  not  carefully  followed 
most  resections  of  the  shoulder  will  result  in  a  flail  artic- 
ulation which  renders  the  limb  almost  useless.  The 
same  condition  is  apt  to  follow  any  injury  or  treat- 
ment causing  paralysis  or  over-stretching  of  the  deltoid 
muscle.  Temporary  inhibition  of  the  muscles  activat- 
ing the  joints  is  a  peculiarity  of  all  joint  injuries.  The 
period  of  inhibition  is  usually  proportional  to  the  trau- 
matism and  may  last  for  many  weeks.  In  the  case  of 
the  shoulder  it  is  extremely  important  to  keep  the 
humerus  in  contact  with  the  glenoid  cavity  and  to  sup- 
port the  arm  until  the  muscles  have  regained  their  tone. 
Moreover,  the  danger  of  a  flail  joint  being  so  great 
after  resection,  it  is  better  to  play  for  complete  anky- 
losis which  gives  a  strong  and  useful  member  if  the  an- 
kylosis is  good.  The  position  to  be  sought  is  one  of  ab- 
duction to  90°  and  rotation  out.  The  movements  of 
the  scapula  on  the  thorax  will  then  allow  the  arm  to  be 
approached  to  the  side  and  the  hand  to  pass  the  median 
plane.  If,  on  the  other  hand,  ankylosis  takes  place  with 
the  arm  at  the  side,  the  movements  of  the  scapula  will 
not  compensate  in  the  slightest  degree,  and  the  arm  will 
remain  fixed  to  the  side  of  the  body.  Furthermore,  if 
ankylosis  is  not  complete,  a  range  of  motion  from  ab- 


FRACTURES  AND  WOUNDS  OF  JOINTS        115 

duction  to  adduction  is  far  more  easily  acquired,  on 
account  of  the  greater  power  of  the  adductor  muscles 
and  because  the  weight  of  the  arm  does  not  have  to  be 
overcome.  Hence  the  adducted  (i.  e.,  arm  at  side)  posi- 
tion is  absolutely  contraindicated. 

During  the  first  weeks  after  reception  of  the  injury 
the  arm  should  be  suspended  as  for  high  fracture  of  the 
humerus,  but  no  traction  should  be  employed.  The 
correct  position  for  suspension  is  for  the  humerus  to  be 
at  90°  with  the  body  and  midway  between  the  coronal 
and  sagittal  planes.  For  the  later  stages  of  treatment  an 
aeroplane  splint  may  be  used,  or  the  arrangement  of 
Thomas  splints  shown  in  Fig.  14.  If  wounds  at  the 
shoulder  interfere  with  the  ring  of  the  arm  splint  a 
Thomas  leg  splint  may  be  used,  the  ring  being  slipped 
over  the  opposite  arm  and  the  chest  being  between  the 
bars.  Traction  must  not  be  employed.  It  is  better, 
however,  to  keep  the  arm  suspended  until  ankylosis  or 
return  of  function  takes  place.  Suspension  allows  of  a 
certain  amount  of  motion  continuously  at  the  articula- 
tion and  favors  a  return  of  normal  movement.  It  also 
facilitates  massage,  and  the  patient,  being  able  to  move 
the  arm,  regains  control  of  it  much  more  rapidly. 

These  cases  should  never  be  allowed  a  sling.  If  the 
patient  must  be  up  before  function  has  returned  he 
should  wear  a  corset  and  a  hinged  support  for  the  arm. 

ELBOW 

Fractures  of  the  elbow  joint,  even  if  infected,  are  not, 
as  a  rule,  dangerous  to  life,  but  are  difficult  to  treat  on 


116     GUN-SHOT  FRACTURES  OF  EXTREMITIES 

account  of  the  tightness  and  irregularity  of  the  articu- 
lation. 

Transport: 

Murray's  modification  of  the  Thomas  arm  splint 
(Fig.  12  B)  or  Jones'  humerus  splint  (Fig.  13)  may 
be  used.  With  the  former,  the  arm  being  in  the  straight 
position,  a  slight  amount  of  traction  is  indicated,  but 
with  the  latter  none  is  required. 

Operative  treatment: 

Any  fracture  involving  the  joint  surfaces  is  apt  to 
result  in  ankylosis  more  or  less  complete.  The  loss  of 
the  movements  of  flexion  and  extension  is  not  so  serious 
as  the  loss  of  pronation  and  supination  of  the  forearm. 
The  worst  result  that  can  happen  is  a  flail  articulation, 
and  this  often  follows  injudicious  resection. 

In  deciding  upon  the  treatment  to  be  adopted  in  any 
individual  case,  the  surgeon  must  not  only  consider  the 
extent  of  the  injury  but  also  the  occupation  of  the  pa- 
tient in  civil  life  and  the  result  which  will  be  most  de- 
sirable for  him. 

Complete  resection  of  the  elbow,  performed  by  sur- 
geons who  are  familiar  with  the  technique  and  the  very 
important  after-treatment,  generally  gives  excellent  re- 
sults as  regards  motion  and  to  a  certain  extent  as  re- 
gards power;  but  occasionally  it  fails,  producing  a  flail 
articulation.  It  is  therefore  exceedingly  doubtful 
whether  complete  resection  should  be  recommended  to 
the  average  surgeon  who  does  not  follow  the  after-treat- 
ment himself.     Partial  and  atypical  resections  are  often 


FRACTURES  AND  WOUNDS  OF  JOINTS        117 

sufficient  to  prevent  infection,  and  as  they  generally 
become  ankylosed  during  repair  they  are  probably  bet- 
ter operations  for  laborers  or  others  needing  a  power- 
ful arm. 

It  is  very  difficult  to  lay  down  strict  rules.  When 
possible,  the  question  should  be  put  before  the  patient ; 
and  the  surgeon,  after  explaining  the  situation  fully  to 
him  as  to  probable  and  possible  results,  both  good  and 
bad,  should  be  led  by  his  wish. 

Early  operations: 

Non-infected  Cases. —  (a)  Perforating  bullet 
wounds  with  punctate  orifices  should  not  be  operated 
upon,  no  matter  what  the  extent  of  fracture. 

(b)  In  wounds  opening  the  joint  but  without  frac- 
ture or  lodged  foreign  bodies,  the  synovia  should  be 
sutured  and  the  soft  parts  closed  by  primary  or  delayed 
primary  suture. 

(c)  In  wounds  with  lodged  foreign  bodies  and  slight 
splintering  of  the  joint  surfaces,  the  foreign  bodies  and 
bone  splinters  which  enter  the  articulation  and  might 
interfere  with  its  function  should  be  removed,  together 
with  all  lacerated  and  contaminated  tissue.  The  syno- 
via should  be  closed  if  possible  and  the  soft  parts  treated 
accordi^  g  to  indications. 

(d)  If  there  is  a  loss  of  substance  on  one  side  of  the 
bearing  surface  (the  trochlear,  for  example),  resection 
is  indicated  if  lateral  deviation  is  probable. 

(e)  If  most  of  the  joint  is  smashed,  one  must  decide 
between  complete  resection  in  the  hope  of  getting  a 
movable  joint,  and  simple  drainage  or  partial  resection 


118     GUN-SHOT  FRACTURES  OF  EXTREMITIES 

with  ankylosis  in  view.     The  nature  of  the  operation 
will  depend  upon  the  extent  of  comminution. 

Cases  in  Which  Infection  is  Established. — 
Arthrotomy  in  generally  the  best  operation  for  all 
cases  except  those  in  which  there  is  extensive  comminu- 
tion at  the  ends  of  the  bones,  when  resection  should  be 
performed.  Resection  is  the  best  and  quickest  method 
of  terminating  infection,  but  if  it  means  extensive  re- 
moval of  bone  (for  fractures  may  extend  halfway  up 
the  humerus  or  down  the  forearm  and  it  is  difficult  to 
draw  a  limiting  line)  it  is  better  for  the  patient  to  suf- 
fer a  long  course  of  suppuration  and  retain  a  stiffened 
arm  than  to  have  a  flail  forearm. 

When  enlargement  of  the  wounds  does  not  afford 
sufficient  drainage,  the  typical  incision  for  arthrotomy 
should  be  made  along  the  outer  border  of  the  olecranon. 
This  will  drain  the  entire  articulation  and,  together  with 
enlargement  of  the  original  wounds,  should  suffice.  On 
account  of  the  superficiality  of  the  elbow  no  tubes  are 
necessary. 

Resection: 

The  Oilier  incision  is  best,  as  it  gives  access  and  good 
drainage,  and  the  ends  of  the  bones  are  not  so  apt  to 
project  through  the  wound  during  the  after  treatment 
as  with  the  letter  H  incision.  The  incision  passes  down- 
ward, from  the  commencement  of  the  external  epicon- 
dylar  ridge,  along  its  posterior  border,  to  its  tip,  then 
obliquely  downward  and  inward  to  the  middle  of  the 
base  of  the  olecranon  process,  and  straight  downward 


FRACTURES  AND  WOUNDS  OF  JOINTS        119 

along  the  posterior  border  of  the  ulna.  The  operation 
must  be  entirely  sub-periosteal,  even  to  conserving  the 
periosteum  of  the  minutest  fragments.  For  the  hu- 
merus the  section  of  the  bones  should  pass  through  the 
epicondyles,  but  it  may  sometimes  be  necessary  to  go  a 
little  higher;  for  the  ulna,  just  so  as  to  remove  the  ar- 
ticular surface  of  the  coronoid  process;  for  the  radius, 
through  the  neck.  Hemi-resections  do  not  succeed.  All 
the  cartilage  must  be  removed  from  all  the  bones.  The 
head  of  the  radius  must  be  removed,  or  supination  will 
be  lost.  The  wound  is  merely  filled  very  lightly  with 
sterile  gauze,  which  should  not  be  removed  until  the 
eighth  or  ninth  day. 

Amputation: 

Amputation  should  never  be  performed  for  injuries 
to  the  elbow  if  the  pulse  is  present  at  the  wrist,  even  if 
more  than  one  of  the  nerves  is  divided. 

Mechanical  treatment: 

All  wounds  of  the  elbow  do  better  by  suspension  than 
by  any  other  form  of  treatment.  The  joint,  although 
at  rest,  moves  slightly,  and  if  there  is  any  chance  what- 
ever of  escaping  ankylosis  this  chance  will  be  pre- 
served. For  injuries  not  requiring  resection  the  fore- 
arm and  arm  are  suspended  as  for  fractures  of  the  lower 
end  of  the  humerus,  but  no  traction  is  used.  When  in- 
fection is  present  a  slight  separation  of  the  joint  sur- 
faces is  desirable  and  the  arm  should  be  hung  by  the 
forearm  alone  (Fig.  38).  If  greater  separation  of  the 
joint   surfaces   is   required,   the   suspending  pulley   is 


120     GUN-SHOT  FRACTURES  OF  EXTREMITIES 

shifted  nearer  to  the  foot  of  the  bed,  thus  increasing 
traction.  As  infection  subsides  the  pulley  is  moved 
toward  the  head  of  the  bed  until  the  desired  amount  of 
flexion  at  the  elbow  is  obtained,  and  the  weight  of  the 
upper  arm  is  also  suspended,  so  that  the  patient  may 


Fig.  38. — Method  of  treating  in- 
fected wounds  of  the  elbow 
joint  by  suspension.  Note  that 
the  upper  arm  is  not  supported. 

make  attempts  at  motion  and  thereby  possibly  prevent 
ankylosis. 

In  complete  resections  entire  restoration  of  the  joint 
is  the  goal  aimed  at.  In  order  to  avoid  stretching  the 
muscles  and  separating  the  ends  of  the  bones,  the  limb 


FRACTURES  AND  WOUNDS  OF  JOINTS        121 

should  be  slung  as  for  fracture  of  the  humerus  (Fig.  16) , 
but  without  any  traction.  There  will  be  enough  un- 
conscious motion  for  the  first  week,  but  after  that 
time  the  forearm  should  be  flexed  and  extended  a  little 
more  each  day,  preferably  by  the  patient  himself  and 
never  so  as  to  cause  lasting  pain.  Active  motion  must  be 
encouraged  throughout  the  period  of  convalescence  for 
two  reasons:  to  improve  the  nutrition  of  the  muscles, 
and  to  mold  the  new  articulation;  the  latter  being  ac- 
complished by  the  pulling  of  the  muscles  on  the  perios- 
teum. 

If  suspension  is  not  available,  a  double  gutter  splint 
with  hinged  side  pieces  forming  a  joint  at  the  elbow  may 
be  used.  The  hinges  permit  the  necessary  motion. 
Non-articulated  splints  should  not  be  employed. 

A  thorough  course  of  sun  treatment  is  particularly 
valuable  to  these  cases,  both  for  healing  the  wounds 
and  for  preserving  the  tone  of  the  muscles. 

WRIST 

Wounds  and  fractures  are  seldom  confined  to  the  car- 
pus alone,  and  usually  either  the  inferior  radio-ulnar 
articulation  or  the  metacarpus  is  also  involved.  It  is 
consequently  necessary  to  consider  all  the  articulations 
as  one  as  far  as  treatment  is  concerned. 

Gun-shot  injuries  in  the  region  of  the  wrist,  although 
not,  as  a  rule,  dangerous  to  life,  are  particularly  serious 
in  regard  to  loss  of  function,  especially  if  the  wounds 
become  infected.  The  tendons  about  the  wrist  are  fre- 
quently lacerated  or  divided;  and  if  infection  occurs 


122     GUN-SHOT  FRACTURES  OF  EXTREMITIES 

they  become  irreparably  embedded  in  cicatricial  tissue 
when  not  destroyed  in  the  infective  process.  It  is  there- 
fore imperative  that  all  injuries  likely  to  become  in- 
fected be  operated  upon  at  the  earliest  possible  moment 
to  remove  not  only  foreign  bodies  but  also  pieces  of 
bone  which,  if  infection  should  ensue,  would  give  rise 
to  protracted  suppuration.  As  the  wrist  is  seldom  cov- 
ered by  clothing,  pieces  of  fabric  are  seldom  entrained 
into  it  by  projectiles,  but  fragments  of  shell  or  grenade, 
however  minute,  are  apt  to  cause  infection  which  some- 
times develops  in  a  peculiarly  slow  and  insidious  way. 

Transport: 

Flat  splints  should  never  be  used  for  injuries  of  the 
wrist  and  hand.  An  efficient  splint  for  transport  may 
be  made  of  the  wire  ladder  splinting  furnished  by  the 
Red  .Cross. 

Operative  treatment: 

As  a  movable  wrist  is  out  of  the  question  once  sup- 
puration is  established,  resection  is  indicated  in  all  cases 
of  fracture  of  the  carpus  except  those  showing  bullet 
wounds  with  punctate  orifices.  The  resection  should 
not  be  typical,  as  for  tuberculosis,  but  should  gener- 
ally be  confined  to  the  fractured  bones  with  due  regard 
to  the  lateral  deformities  which  may  ensue.  The  semi- 
lunar and  scaphoid  should  not  be  removed  and  the 
cuneiform  left,  for  instance,  as  a  crippling  distortion 
would  result.  When  the  extremity  of  the  radius  has 
been  destroyed  or  removed  the  head  of  the  ulna  should 


FRACTURES  AND  WOUNDS  OF  JOINTS        123 

be  resected.  In  general,  the  trapezium  and  trapezoid 
on  one  side  and  the  unciform  on  the  other  should  be  pre- 
served. 

If  the  wound  and  fracture  involve  the  metacarpus 
and  the  carpus  (particularly  if  the  tendons  of  the  cor- 
responding finger  are  affected,  as,  for  example,  the  os 
magnum,  the  third  metacarpal  and  tendons  of  the  mid- 
dle finger)  a  good  operation  is  to  amputate  the  middle 
finger  and  split  the  hand  right  down  to  the  carpus,  re- 
moving all  the  fractured  bones.  The  halves  of  the  hand 
can  be  at  once  reunited  if  the  wound  is  clean,  or  sutured 
secondarily  if  it  is  infected. 

For  extensive  resections  of  the  carpus  the  incisions 
for  approach  are  two :  an  external  incision  which  fol- 
lows the  radial  border  of  the  extensor  indicis,  commenc- 
ing at  the  level  of  the  line  joining  the  styloid  processes 
and  extending  to  the  middle  of  the  second  metacarpal; 
and  an  internal  incision  which  commences  just  above  the 
styloid  process  of  the  ulna  and  passes  down  well  to  the 
inner  side  of  the  extensor  minimi  digiti  to  2  cm.  (1  in. ) 
above  the  lower  end  of  the  fifth  metacarpal.  The  ten- 
dons should  be  carefully  retracted  after  dividing  the 
posterior  annular  ligament. 

If  the  lower  ends  of  the  radius  or  ulna  are  resected 
the  periosteum  should  be  preserved  with  the  greatest 
care  in  order  to  obtain  restitution  of  the  extremities  of 
the  bones.  As  for  the  carpals  themselves,  bony  restitu- 
tion is  not  so  important,  for  a  cicatricial  wrist  is  to  be 
desired;  but  the  sub-periosteal  method  should  be 
used  in  order  to  avoid  injury  to  the  overlying  tissues. 


124     GUN-SHOT  FRACTURES  OF  EXTREMITIES 

Mechanical  treatment: 

After  extensive  resection  the  hand  has  to  be  immo- 
bilized in  a  position  of  dorsal  flexion  until  repair  is  es- 
tablished, in  order  to  avoid  the  tendency  to  displacement 
toward  a  position  of  palmar  flexion  due  to  the  greater 
strength  of  the  flexor  muscles.  This  should  be  done  by 
means  of  a  molded  plaster  splint  (Figs.  39  and  40). 
By  using  this  splint  the  thumb  as  well  as  the  palm  is 
well  supported  and  the  fingers  can  be  moved. 


Fig.  39. — Molded  plaster  splint  for  immobili- 
zation of  the  wrist.  (By  the  courtesy  of  M.  le 
Medecin-Major  R.  Leriche). 

When  wet  dressings  have  to  be 'employed,  as  in  infected 
cases,  the  original  plaster  splint  should  be  carefully  re- 
moved at  the  first  dressing  and  another  apphed.  If  the 
first  is  in  good  condition  it  should  be  thoroughly  dried 
and  then  impregnated  with  melted  paraffin;  it  can  sub- 
sequently be  used  for  a  long  time  without  becoming 
softened  by  the  dressing  solutions.  As  an  alternative, 
if  sheets  of  gutta-percha  can  be  had,  they  may  be  heated 
in  hot  water  and  the  splint  molded  out  of  them. 

For  later  treatment,  when  absolute  fixation  is  not 


FRACTURES  AND  WOUNDS  OF  JOINTS        125 

necessary,  one  of  the  cock-up  splints  may  be  used  to 
advantage. 

After  extensive  resections  passive  and  active  motion 
should  be  limited  to  the  fingers  until  repair  is  well  ad- 
vanced. After  limited  resections  passive  and  active 
motions  of  both  wrist  and  fingers  should  be  commenced 
at  the  end  of  a  week. 


Fig.  40. — Method  of  cutting  thicknesses  of  crinoline  to 
make  molded  plaster  splint  for  wrist.  (By  the  cour- 
tesy of  M.  le  Medecin-Major  R.  Leriche). 


HIP 

On  account  of  its  depth  in  a  mass  of  heavy  muscles, 
its  close  relation  to  the  cavity  of  the  pelvis  and  the  or- 
gans contained  therein,  and  the  great  danger  of  anae- 
robic infection,  gun-shot  injuries  of  the  hip  joint  are  ex- 
tremely serious.  It  is  probable  that  only  exceptional 
cases  reach  the  surgeon,  the  greater  number  being  killed 
immediately  or  dying  of  hemorrhage  and  shock.  Of 
those  who  do  live  to  reach  the  surgeon,  many  succumb 
from  complicating  injuries  to  the  intestine  or  bladder, 
anj^  others  from  rapid  development  of  infection  due  to 
the  favorable  field  for  the  growth  of  anaerobes  afforded 
by  the  lacerated  muscles.  * 


126     GUN -SHOT  FRACTURES  OF  EXTREMITIES 

In  no  class  of  cases  is  early  operation  more  impera- 
tively demanded  to  save  life,  yet  more  often  prevented 
on  account  of  shock. 

Transport: 

Fractures  of  the  hip  joint  are  transported  in  the  same 
manner  as  fractures  of  the  upper  part  of  the  shaft  of 
the  femur/ 

Cases  should  remain  at  the  hospital  in  which  they  are 
operated  until  consolidation  is  established.  As  extreme 
abduction  is  necessary  throughout  their  treatment,  if 
they  must  be  transported  they  should  be  put  in  a  splint 
which  will  maintain  such  a  position,  and  the  double 
plaster  of  Paris  spica  should  therefore  be  used. 

Operative  treatment: 

Bullet  wounds  with  punctate  orifices  should  not  be 
operated  upon,  but  such  cases  must  not  be  evacuated 
until  all  danger  of  infection  is  past. 

All  other  wounds  should  receive  operative  treatment 
as  soon  as  the  patient's  condition  permits.  The  nature 
of  the  operation  will  depend  upon  the  character  of  the 
injury  and  whether  infection  is  already  established  or 
not. 

Operations  Before  Evident  Infection. — For 
wounds  of  the  joint  without  bone  injury,  or  those 
merely  complicated  by  grooving  of  the  bone  or  embed- 
ding of  projectiles  therein,  the  treatment  should  be  as 
for  any  other  joint  wound.  Primary  suture  should  not 
be  attempted,  however,  the  wound  being  left  open  for 
delayed  primary  or  secondary  suture. 

'Pages    73-79- 


FRACTURES  AND  WOUNDS  OF  JOINTS        127 

If  there  is  extensive  comminution  of  the  head  and 
neck  of  the  femur,  even  if  it  extends  down  the  shaft, 
complete  sub-periosteal  resection  of  all  the  fragments 
should  be  made  on  account  of  the  great  danger,  if  in- 
fection should  supervene,  of  continued  and  perhaps 
fatal  suppuration  amidst  them.  The  cartilage  of  the 
acetabulum  should  be  removed  in  nearly  all  cases,  be- 
cause, as  there  is  no  hope  of  regaining  an  articulation, 
firm  ankylosis  is  the  result  to  be  sought  for,  and  also 
because  suppuration,  if  it  should  occur,  is  prolonged  by 
the  presence  of  the  cartilage.  When  the  os  innomina- 
tum  has  been  pierced  by  the  missile,  the  bone  fragments 
and  projectile  should  be  removed,  even  if  an  ischio-rectal 
or  an  abdominal  incision  has  to  be  made. 

For  resections  and  extensive  operations  on  the  joint, 
the  approach  from  in  front  should  be  selected  as  easier 
and  causing  less  traumatism  to  the  muscles.  The  pos- 
terior route  would  at  first  sight  seem  preferable  be- 
cause it  affords  dependent  drainage,  but  it  destroys 
the  attachment  of  the  muscles  to  the  trochanter  and 
digital  fossa  (which  will  be  the  most  important  muscles 
in  preventing  dislocation  of  the  femur  on  the  dorsum 
ilia  during  after-treatment).  It  is  therefore  better  not 
to  enlarge  existing  posterior  wounds  except  in  so  far  as 
is  necessary  to  trim  and  clean  them.  The  best  incision 
is  one  which  commences  at  the  antero-inferior  spine  of 
the  ilium  and  passes  outward  and  downward  toward 
the  great  trochanter,  following  in  general  the  direction 
of  the  neck  of  the  femur.  This  incision  is  deepened 
between  the  rectus  femoris  mesally  and  the  tensor  fascia 
femoris  laterally.    The  capsule  of  the  joint  is  split  longi- 


128     GUN-SHOT  FRACTURES  OF  EXTREMITIES 

tudinally  and  then  cut  away  transversely  at  its  attach- 
ment to  the  acetabukim.  If  the  neck  has  not  been  frac- 
tured it  can  be  cut  with  a  large  bone-cutting  forceps  or 
by  a  gigli  saw,  and  the  head  removed. 

Drainage,  if  the  original  wound  does  not  open  pos- 
teriorly, should  be  made  by  a  stab  wound  at  the  border 
of  the  gluteus  maximus.  Two  small  drainage  tubes 
should  be  inserted,  but  only  as  far  as  the  cavity  left  by 
the  removal  of  the  bone.  The  anterior  wound  should 
be  left  open  for  delayed  primary  or  secondary  suture. 

Operations  During  Evident  Infection. — The  same 
remarks  apply  as  for  non-infected  cases  except  that  the 
indications  for  resection  are  more  pronounced.  In- 
juries to  the  bones  likely  to  prolong  infection,  such  as 
fissured  fractures,  should  be  treated  by  typical  resec- 
tion. If  the  bone  injury  is  slight  resection  may  be  post- 
poned as  perhaps  unnecessary.  In  such  cases  the  cap- 
sule should  be  fully  opened;  drainage  tubes  must  never 
be  passed  through  it,  however,  but  should  go  just  to  its 
level. 

Mechanical  treatment: 

In  cases  where  there  is  no  complete  fracture  the  limb 
should  be  suspended  in  flexion  of  the  hip  and  knee  and 
in  moderate  abduction  and  traction.  This  is  most  easily 
accomplished  by  means  of  a  Hodgen's  splint  and  the 
Hennequin  method  of  making  traction  (Fig.  33). 
Such  a  position  is  best  for  drainage  and  is  the  most 
convenient  for  patient  and  attendants.  A  traction  pull 
of  five  or  six  kilos  should  be  sufficient- 


FRACTURES  AND  WOUNDS  OF  JOINTS        129 

In  cases  of  fracture  by  rifle  ball  which  have  not  been 
operated  upon,  and  in  cases  of  resection,  a  position  of 
extreme  abduction  is  indicated,  in  the  first  to  prevent 
coxa  vara,  and  in  the  second  to  keep  the  end  of  the 
femur  in  the  cavity  of  the  acetabulum  and  to  compen- 
sate for  shortening.  In  non-resected  cases  a  certain 
amomit  of  flexion  at  the  hip  is  permissible,  but  not  in 
resected  cases.  The  non-resections  need  strong  trac- 
tion, but  the  resections  should  have  only  slight  traction. 
The  limb  should  therefore  be  suspended  on  a  straight 
splint  (the  straightened  Hodgen's  is  usually  the  most 
convenient),  and  only  slightly  elevated  from  the  bed; 
a  traction  pull  of  from  16  to  18  kilos  to  commence  with 
being  applied  for  the  non-resected  cases  and  of  from 
A  to  5  kilos  for  the  resected  cases.  To  maintain  abduc- 
tion the  sound  limb  must  also  be  suspended  in  marked 
abduction. 

In  the  resected  cases,  as  soon  as  the  danger  of  infec- 
tion is  past  and  the  wounds  are  healing,  it  is  advisable 
to  put  on  a  double  plaster  of  Paris  spica;  this  need  not 
be  carried  below  the  knees. 

Amputation: 

As  disarticulation  at  the  hip  joint  is  an  exceedingly 
shocking  operation,  and  more  so  than  resection,  the 
latter  is  sometimes  preferable  as  a  primary  operation, 
even  when  the  injury  to  the  bones  is  so  extensive  as  to 
make  restoration  of  the  function  of  the  limb  ques- 
tionable. 

There  are  also  cases  in  which  the  pelvis,  as  well  as  the 
hip,  is  infected,  and  in  which  a  disarticulation  would  not 


130     GUN-SHOT  FRACTURES  OF  EXTREMITIES 

benefit  the  pelvic  condition.  For  these,  resection  and 
drainage  would  seem  the  lesser  risk.  In  most  infected 
cases  of  severe  and  extensive  inj  ury  to  the  soft  parts  and 
femur,  however,  amputation  at  the  hip  is  advisable. 

KNEE 

Wounds  of  the  knee  have  aroused  more  interest  and 
controversy  than  those  of  any  other  articulation.  No 
other  joint  demonstrates  so  vividly  the  course  of  nor- 
mal repair  or  infection,  and  it  is  generally  accepted  as 
the  type  as  regards  the  results  of  different  treatments. 
In  the  early  months  of  the  war  nearly  all  wounds  of  the 
knee  became  infected,  and  in  a  very  large  proportion 
amputation  was  performed.  The  usual  treatment  for 
an  infected  knee  was  to  insert  through  and  through 
drains  into  multiple  incisions,  and  suppuration  con- 
tinued until  the  cartilage  disappeared,  after  which  the 
bones  could  become  covered  with  granulations  and  re- 
pair gradually  took  place.  The  patient,  during  this 
long  period,  was  subjected  to  all  the  dangers  of  severe 
sepsis,  and  finally  emerged  (if  he  did  emerge)  without 
the  hmb  or  with  a  stiff  knee,  and  his  viscera  shattered 
by  amyloid  degeneration.  It  was  soon  discovered  that 
resection,  by  removing  the  cartilage  and  affording  free 
drainage  of  all  the  recesses  of  the  joint,  hastened  resolu- 
tion and  repair.  The  greatest  improvement  in  treat- 
ment (and,  in  fact,  a  milestone  in  the  treatment  of  all 
joints)  was  the  discovery  that  by  a  proper  surgical 
(i.  e.,  operative)  cleaning  of  the  wounds  the  joint  cavity 
could  be  closed  with  even  more  impurity  than  wounds 
of  soft  parts,  and  that  infection  could  be  eliminated  in 


FRACTURES  AND  WOUNDS  OF  JOINTS        131 

the  great  majority  of  cases.  More  recently,  observa- 
tions in  a  number  of  cases  of  suppurating  knees  in  the 
service  of  the  author  have  tended  to  prove  that  in  such 
cases  simple  incisions,  sufficient  to  open  the  recesses 
of  the  joint  but  without  the  use  of  drains,  lead  to  rapid 
decline  of  the  infection  and  repair  without  destruction 
of  the  joint. 

Anatomically  the  joint  is  complicated.  Besides  the 
main  bursa  extending  upward  under  the  quadriceps  ex- 
tensor muscle,  there  are  a  variable  number  of  bursae  in 
the  popliteal  space  in  relation  with  the  popliteus  and 
gastrocnemius  muscles,  which  may  or  may  not  be  in- 
volved in  an  infection  of  the  joint.  Usually  they  escape 
until  the  joint  becomes  more  or  less  disorganized.  If 
they  become  infected  they  are  apt  to  cause  abscesses 
which  dissect  their  way  into  the  calf  unless  opened  at  an 
early  date.  The  popliteal  nerves  and  vessels  lie  directly 
behind  the  joint,  and  incisions  to  open  the  popliteal 
bursae  must  be  made  by  careful  dissection.  If  drain- 
age tubes  are  used  in  these  cases  there  is  great  danger 
of  secondary  hemorrhage  from  pressure  ulceration. 

Transport: 

All  injuries  of  the  knee  should  be  transported  from 
the  field  in  a  Thomas  splint  with  traction.  A  well  pad- 
ded, posterior  board  or  wire  ladder  splint  should  be 
used  in  addition,  to  support  the  joint.  For  late  trans- 
portation, the  Thomas  splint  is  good  for  ordinary  cases ; 
for  cases  which  have  been  resected  a  plaster  of  Paris 
splint,  extending  from  the  foot  to  the  waist,  should  be 
employed. 


132     GUN-SHOT  FRACTURES  OF  EXTREMITIES 

Operative  treatment: 

Operative  treatment  varies  greatly  with  the  extent  of 
injury  to  the  joint,  and  also  with  the  absence  or  pres- 
ence of  infection.  The  normal  knee,  in  everyday  life, 
is  more  subject  to  accident  than  any  other  joint;  in 
other  words,  it  is  inherently  weak.  It  is  important, 
therefore,  that  the  treatment  should  be  directed  toward 
preserving  strength  and  avoiding  any  sacrifice  of  liga- 
ments or  tendons.  On  the  other  hand,  if  part  of  the 
bone,  sufficient  to  destroy  the  bearing  surface  of  the 
joint,  has  been  lost,  it  is  impossible  to  restore  it;  and  in 
order  to  obtain  a  strong  and  useful  limb  it  is  advisable 
to  resect,  as  an  ankylosed  knee  is  better  than  a  weak  and 
deformed  one  and  one  subject  to  recurring  accidents. 

As  the  type  of  operation  to  be  performed  depends 
chiefly  upon  the  anatomical  lesions,  the  cases  will  be 
grouped  accordingly,  and  not  by  the  absence  or  pres- 
ence of  infection,  the  only  exception  being  perforating 
bullet  fractures  and  wounds  with  punctate  orifices 
which  should  not  be  operated. 

(a)  Wounds  entering  the  articulation,  with  or  with- 
out lodged  projectiles,  hut  without  injury  to  the  hones. 
These  should  be  pared  and  excised  as  usual,  the  foreign 
bodies  removed,  the  sj^novia  sutured  if  the  operation 
takes  place  at  an  early  date,  and  the  superficial  wound 
closed  by  primary  or  delayed  primary  suture.  If  the 
projectile  has  passed  across  the  joint,  the  latter  should 
be  opened  at  the  opposite  side  so  as  to  provide  sufficient 
access  to  not  only  extract  the  projectile  but  to  inspect 
the  cavity  and  remove  all  contaminated  tissue.  If  ob- 
viously infected  the  wounds  should  merely  be  left  open. 


FRACTURES  AXD  WOUNDS  OF  JOINTS        133 

and  if  the  joint  has  been  distended  with  pus  incisions 
should  be  made  at  each  side  of  the  thigh  into  the  upper 
part  of  the  quadriceps  bursa  and  each  side  of  the  patella 
tendon.     No  tubes  should  be  used. 

(b)  Lodged  projectiles  in  the  epiphyses  hut  not  en- 
tering the  joint.  These  should  be  removed  and  the  tract 
carefully  excised.  If  the  joint  is  full  of  blood  it  should 
be  opened  and  washed  out  with  normal  saline.  Unless 
it  is  infected  the  opening  into  it  should  be  sutured.  The 
original  wound  should  be  left  for  delayed  primary  su- 
ture. If  the  joint  is  infected  secondarily  from  a  pro- 
jectile lodged  in  an  epiphysis  it  is  usually  best,  on  ac- 
count of  the  infection  being  established  in  the  bone,  to 
resect  the  joint. 

(c)  Fractures  involving  only  a  small  portion  of  the 
bony  surfaces  and  not  endangeiing  the  future  relatioris 
of  the  bones.  In  early  cases,  before  infection,  the  loose 
fragments  should  be  removed  and  the  joint  closed.  If 
the  joint  is  infected  and  the  wounds  of  the  bone  can- 
not be  isolated  from  the  joint  and  drained  directly  to 
the  exterior,  it  is  wiser  to  resect. 

(d)  Fractures  with  loss  of  substance  destroying  the 
bearing  of  the  joint  (one  condyle  of  the  femur,  for  in- 
stance, or  one  tuberosity  of  the  tibia ) .  These  should  be 
resected  whether  infected  or  not. 

(e)  Comminution  of  the  joint.  These  cases  should 
be  resected  or  amputated. 

(f)  Fractures  with  extensive  fragmentatio7i.  These 
usually  demand  amputation. 

(g)  Cases  in  which  simple  drainage  has  been  made 
without    causing    the    infection    to    subside    and    with 


134     GUN-SHOT  FRACTURES  OF  EXTREMITIES 

marked  signs  of  general  sepsis  persisting.  These  are 
best  treated  by  resection  or  amputation,  depending 
upon  the  strength  of  the  patient.  If  there  is  doubt  it  is 
advisable  to  amputate. 

Technique  of  resection: 

The  resection  should  always  be  as  conservative  as 
possible,  and  just  enough  bone  removed  to  obtain  a 
good  surface  for  apposition.  In  cases  without  fracture 
the  cartilage  can  be  removed  from  the  posterior  aspect 
of  the  condyles  after  taking  the  saw  cut.  The  patella 
should  usually  be  excised.  The  saw  cut  should  be  made 
so  that  when  the  sawed  surfaces  are  in  apposition  the 
knee  will  be  flexed  to  about  10°.  It  is  not  necessary 
to  excise  the  synovia;  the  cartilage  is  the  structure  that 
retards  and  restricts  repair.  In  clean  cases  the  bones 
should  be  fixed  in  apposition  with  nails,  and  the  wound 
closed.  Resections  in  infected  cases  should  be  left  open, 
and  the  ends  of  the  bones  kept  separated  by  traction 
until  the  infection  disappears. 

Delajxd  or  fibrous  union  occurs  sometimes  after  re- 
sections of  infected  joints  and  necessitates  a  secondary 
resection.  This  should  not  be  done  until  the  wound  has 
been  healed  for  a  sufficient  time  to  eliminate  the  danger 
of  post-operative  infection.  As  these  secondary  resec- 
tions, and  other  late  resections  for  demority,  do  not 
always  unite  well  it  is  very  good  practice  to  put  in  an 
inlay  graft.    If  this  is  done  failure  will  seldom  occur. 

There  are  some  things  which  should  not  be  done  in 
operations  on  the  knee.  The  patella  ligament  should 
never  be  divided  unless  during  resection,  for  the  knee 


FRACTURES  AND  WOUNDS  OF  JOINTS        135 

in  most  instances  will  have  to  be  resected  later ;  if  suffi- 
cient access  is  unattainable  by  means  of  curved  lateral 
incisions,  the  patella  and  its  tendon  and  ligament  may 
be  split  longitudinally.  Extended  experience  has 
proved  that  the  method  of  treating  infected  knees  wide 
open  in  flexion  is  undesirable.  It  is  bad  practice  to 
drain  through  the  popliteal  space;  it  is  much  better  to 
resect. 

Mechanical  treatment: 

All  cases,  with  the  exception  of  non-infected  resec- 
tions, are  best  treated  by  suspension  in  a  Hodgen's  or 
Thomas  splint  bent  to  165°  at  the  knee,  and  just  enough 
traction  to  steady  the  limb — a  weight  of  3  to  4  kilos  is 
sufficient.  It  is,  however,  impossible  to  immobilize  a 
limb  sufficiently  after  resection  of  the  knee  by  suspen- 
sion without  a  firm  support  behind  the  thigh  and  leg 
to  prevent  displacement  and  angulation.  This  can  be 
accomplished  by  means  of  a  molded  plaster  splint  ex- 
tending from  the  gluteal  fold  to  the  foot.  The  splint 
should  be  removed  when  hard  and  dried,  and  paraffined 
as  has  already  been  described  in  dealing  with  the  wrist. 
A  gutta-percha  splint  is  equally  suitable.  With  this 
rigid  support  suspension  in  a  Hodgen's  splint  has  given 
excellent  results.  Resections  for  infection  should  be 
treated  with  enough  traction  to  keep  the  ends  of  the 
bones  apart  until  the  infection  disappears,  when  they 
should  be  allowed  to  approximate.  Non-infected  resec- 
tions, and  those  in  which  infection  has  subsided,  should 
be  immobilized  as  absolutely  as  possible  in  order  to 
promote  firm  union.     For  this  purpose  a  plaster  of 


136     GUN-SHOT  FRACTURES  OF  EXTREMITIES 

Paris  splint  extending  from  the  foot  to  above  the  hip 
joint  should  be  used. 


ANKLE 

The  calcaneo-astragalar  articulation  will  be  studied 
in  this  group,  because  no  definite  separation  can  be 
made  between  fractures  of  the  two  articulations. 

In  considering  the  treatment  of  injuries  of  this  re- 
gion, and  also  those  of  the  anterior  tarsus  and  metatar- 
sus, two  main  points  must  be  kept  in  view:  firstly 
(orthopedic),  the  conservation  of  the  function  of  the 
foot;  secondly,  the  peculiarities  of  the  course  taken  by 
infection.  The  orthopedic  question  is  dealt  with  in 
the  description  of  the  operations  for  each  region. 

Infections  of  the  short  bones  are  apt  to  take  a  slow 
and  insidious  but  persistent  course,  the  infective  osteitis 
gradually  extending  and  involving  the  articulations  and 
adjacent  bones.  Unless  treated  vigorously  by  remov- 
ing enough  of  the  bone  or  bones  to  afford  free  drainage, 
suppuration  is  apt  to  persist  for  months  and  may,  from 
absorption  of  bone,  destroy  the  usefulness  of  the  foot 
or  necessitate  amputation.  The  surgeon  will  conse- 
quently do  well  to  anticipate  this  irregular  destruction 
by  a  resection  on  orthopedic  principles  which  will 
arrest  the  infection  and  provide  a  useful  foot.  More- 
over, particularly  in  wounds  of  the  anterior  tarsus,  in- 
fections are  apt  to  take  a  very  violent  course,  involvmg 
the  sole  of  the  foot  and  ascending  the  tendon  sheaths — 
so  much  so  that  wounds  of  the  foot  are  not  only  exceed- 
ingly dangerous  to  the  member  but  to  life  itself.    This 


FRACTURES  AND  WOUNDS  OF  JOINTS        137 

explains   what   might   otherwise   seem   extraordinarily 
radical  operations  for  wounds  of  this  region. 

Transport: 

The  Cabot  posterior  wire  splint  should  be  used  for 
transport  fro:n  the  field.  For  late  transport  some  form 
of  plaster  of  Paris  splint  is  desirable. 

Operative  treatment: 

As  the  ankle  joint,  on  account  of  the  tight  mortise 
formed  by  the  malleoli,  is  very  difficult  to  drain,  it  is 
often  better  to  remove  the  astragalus  than  to  await  a 
prolonged  and  problematic  recovery  by  simple  drain- 
age, all  the  more  so  because  the  orthopedic  result  after 
removal  of  the  astragalus  is  excellent.  On  the  other 
hand,  it  is  extremely  important  to  preserve  the  malleoli 
and  the  mortise  between  them,  as  well  as  the  os  calcis 
which  should  never  be  removed  in  toto.  In  infected 
fractures  of  the  malleoli  above  or  of  the  os  calcis  be- 
low, therefore,  the  astragalus,  wlien  it  is  necessary  to 
obtain  drainage,  should  be  sacrificed,  even  if  little  in- 
jured, in  order  to  preserve  the  other  bones.  In  primary 
operations  for  wounds  or  projectiles  lodged  in  the  astra- 
galus, if  it  is  found,  in  curetting  out  the  bone,  that  the 
posterior  part  of  the  body  has  to  be  removed  to  such  an 
extent  as  to  destroy  its  form  and  bearing  power,  the 
whole  bone  should  be  excised.  On  the  other  hand,  par- 
tial resections  of  the  head  give  good  orthopedic  results. 

Most  fractures  of  the  astragalus  should  be  treated 
by  total  excision,  even  if  caused  by  rifle  balls  and  pre- 
sumably uninfected. 


138     GUN-SHOT  FRACTURES  OF  EXTREMITIES 

In  wounds  and  fractures  of  the  os  calcis  resections 
should  be  as  limited  as  possible,  and  the  tuberosity  and 
plantar  surface  should  never  be  removed.  The  gap 
caused  by  removal  of  the  astragalus  gives  sufficient  room 
to  treat  more  conservatively  fractures  of  the  malleoli 
above  and  of  the  os  calcis  below. 

The  incisions  for  excision  of  the  astragalus  are  made 
on  both  sides  of  the  foot.  The  outer  and  more  impor- 
tant begins  from  5  to  6  cm.  .(2  to  2l/o  in.)  above  the 
extremity  of  the  external  malleolus  and  passes  down- 
ward along  the  anterior  border  of  the  fibula,  curving 
gently  forward  in  the  direction  of  the  interval  between 
the  fourth  and  fifth  toes  to  end  at  the  cuboid.  It  is 
deepened  to  the  outer  side  of  the  peroneus  tertius  and 
anteriorly  to  the  peroneus  brevis.  From  its  center  a  short 
straight  incision  is  carried  backward  and  downward  to 
the  tip  of  the  external  malleolus;  this  exposes  the  in- 
ferior tibio-fibular,  the  tibio-astragalar  and  the  astra- 
galo-navicular  articulations.  The  internal  incision, 
about  6  cm.  (2l/2  in.)  long,  curves  along  the  front  of 
the  internal  malleolus  to  its  tip ;  from  the  center  of  this 
incision  another  is  carried  forward  and  slightly  down- 
ward to  the  navicula,  but  does  not  cross  the  tibialis  an- 
ticus.  This  opens  the  tibio-astragalar  and  the  astragalo- 
navicular  articulations  and  only  divides  the  extreme 
anterior  fibers  of  the  internal  lateral  ligament.  The 
astragalus  should  be  removed  sub-periosteally  with  the 
sharp  periosteal  elevator,  carefully  avoiding  any  in- 
jury to  the  over-lying  soft  parts.  The  gaping  wound 
should  be  very  lightly  filled  with  gauze  from  each  side. 
No  through  and  through  drainage  should  be  used. 


FRACTURES  AND  WOUNDS  OF  JOINTS        139 

For  exposure  of  the  os  calcis  the  incision  is  made  on 
the  outer  side  of  the  foot  in  the  shape  of  the  letter  L, 
the  vertical  portion  being  at  the  anterior  border  of  the 
tendo-Achillis  and  the  horizontal  parallel  with  the  sole 
at  the  junction  of  the  thin  skin  with  the  thick  skin  of 
the  sole.  This  affords  plenty  of  room  for  all  operations 
upon  the  calcis,  particularly  in  conjunction  with  the 
original  wounds. 

Mechanical  treatment: 

For  simple  drainage  of  the  ankle,  and  for  all  atypical 
operations,  suspension  in  a  Hodgen's  splint  with  a  slight 
traction  by  means  of  Sinclair's  skate  (Fig.  31  D)  is 
by  far  the  best  treatment. 

The  after-treatment  of  resections  of  the  astragalus 
by  suspension  is  more  difficult,  on  account  of  the  tend- 
ency to  displacement  of  the  foot,  but  it  is  advisable  to 
use  suspension  and  traction  in  infected  cases  until  the 
infection  is  arrested.  For  clean  cases  of  resection  the 
best  method  is  to  employ  a  plaster  of  Paris  splint  reach- 
ing from  the  toes  to  the  knee.  This,  of  course,  has  to 
be  removed  at  every  dressing,  but  in  clean  cases  the 
dressings  are  so  infrequent  that  this  is  no  great  incon- 
venience. Increased  comfort  will  be  afforded  to  the 
patient  if  the  limb  in  the  splint  be  suspended. 

Old  fistulas  of  the  astragalus  and  vicious  union  of 
the  ankle  and  foot  are  best  treated  by  astragalectomy. 
The  position  of  the  foot  must  be  carefully  watched 
after  excision  of  the  astragalus.  At  first  the  foot  hangs 
loosely,  but  as  repair  takes  place  it  gradually  becomes 
drawn  up  against  the  tibia  and  fibula.    If  the  splint  is 


140     GUN-SHOT  FRACTURES  OF  EXTREMITIES 

not  properly  applied  the  foot  may  be  displaced  too  far 
forward  or  backward  and  become  useless;  there  is  also 
a  tendency  to  inward  rotation,  which  must  be  met  and 
corrected.  A  firm  cicatricial  union  should  be  sought  for 
rather  than  a  new  articulation;  early  movements  are 
not  indicated,  therefore,  nor  should  the  patient  attempt 
to  walk  until  cicatrization  is  complete,  i.  e.,  three  or 
four  months  on  an  average.  JNIuch  attention  must  be 
given  to  the  toes  in  order  to  prevent  incurvation;  they 
must  be  massaged  daily  and  their  active  motion  en- 
couraged. When  repair  is  sufficiently  advanced  to  per- 
mit walking,  a  shoe  with  lateral  steel  braces  extending 
up  the  leg  should  be  fitted  in  order  to  prevent  lateral 
deviation  of  the  foot. 

Tarsus  and  Metatarsus 

As  has  already  been  stated  in  regard  to  the  ankle  and 
posterior  tarsus,  operations  for  fractures  of  this  region 
should  be  performed  at  the  earliest  possible  moment  to 
avoid  infection,  with  its  deplorable  consequences,  not 
only  to  the  articulations  and  tendons  of  the  foot,  but  to 
life  itself. 

Transport: 

As  for  fractures  of  the  ankle.  . 

Operative  treatment: 

The  question  as  to  amputation  or  resection  in  these 
cases  is  decided  by  the  amount  of  destruction  of  the  soft 


FRACTURES  AND  WOUNDS  OF  JOINTS        141 

parts,  tendons  and  skin.  Even  extensive  injuries  in- 
volving the  greater  part  of  the  tarsus  can  be  treated  by 
resection  with  good  orthopedic  results  if  sufficient  soft 
parts  remain. 

The  nature  of  the  resection  will  depend  on  the  extent 
of  injury  transversely.  For  wounds  and  fractures  of 
single  bones,  partial  resection  and  ablation  of  all  torn 
tissues  and  foreign  bodies  suffices  as  a  rule,  when  it  is 
done  primarily  and  before  infection  is  established. 
After  infection  has  set  in  the  affected  bones  should  be 
entirely  removed.  When  the  bones  are  fractured  trans- 
versely across  the  foot,  resection  of  the  entire  anterior 
tarsus,  with  partial  resection  of  what  metatarsals  may 
be  injured,  gives  excellent  results.  Resections  of  the 
bones  at  one  side  of  the  foot  are  not  so  satisfactory  on 
account  of  the  tendency  to  lateral  deviation,  and  they 
should  not  be  performed  unless  at  least  half  or  more 
of  the  tarsus  is  preserved.  For  more  extensive  injuries 
it  is  best  to  resect  the  entire  tarsus,  removing  the  astra- 
galus but  always  leaving  the  os  calcis. 

Injuries  to  the  metatarsus,  if  severe,  may  be  treated 
by  resection  combined  with  disarticulation  of  the  corre- 
sponding toes. 

For  resection  of  the  tarsus  the  incisions  already  de- 
scribed for  the  astragalus  and  os  calcis,  and  the  typical 
incisions  for  navicula,  cuboid  and  cuneiforms  advised  by 
Oilier,  are  used  in  conjunction  with  the  original 
wounds.  The  incisions  for  resection  of  the  anterior  tar- 
sus are  four  in  number:  one  passing  along  the  inner 
border  of  the  foot  from  the  tubercle  of  the  navicula  to 
the  articulation  of  the  cuneiform  with  the  first  metatar- 


142     GUX-SHOT  FRACTURES  OF  EXTREMITIES 

sal;  a  second  passing  close  to  the  outer  border  of  the 
extensor  hallucis,  uncovering  the  navicula  and  passing 
between  the  internal  and  middle  cuneiforms;  a  third 
passing  between  the  extensor  tendons  of  the  fourth  and 
fifth  toes  and  opening  the  articulation  between  the  ex- 
ternal cuneiform  and  the  cuboid;  and  a  fourth  passing 
along  the  superior  border  of  the  peroneus  brevis  and 
uncovering  the  cuboid.  It  is  not  necessary  to  remove 
the  heads  of  the  metatarsals  or  of  the  astragalus  in  re- 
sections of  the  anterior  tarsals.  The  large  cavity  left 
by  extensive  resections  should  be  gently  filled  with 
gauze,  which,  in  the  clean  cases,  should  not  be  removed 
for  eight  or  ten  days. 

When  the  wounds  involve  the  sole,  threatening  in- 
fection of  the  tendon  sheaths  or  already  infected,  a  suc- 
cessful method  of  treatment  has  been  to  split  the  foot 
longitudinally,  by  a  dorsal  and  plantar  incision,  the  two 
joining  in  the  commissure  between  the  toes.  The  halves 
of  the  foot  are  then  separated,  and  the  bones  resected 
if  necessary;  when  infection  is  present  the  former  are 
kept  apart  until  it  has  subsided.  These  incisions,  by 
laying  open  the  dense  tissues  of  the  sole,  have  been  very 
efficacious  in  limiting  infection  and  have,  at  the  same 
time,  given  satisfactory  functional  results.  Such  a  lon- 
gitudinal splitting  in  the  sagittal  planes  is  less  destruc- 
tive than  another  which  has  been  recommended ;  namely, 
a  splitting  of  the  sole  away  from  the  bones  by  incisions 
along  the  border  of  the  foot.  These  splitting  proce- 
dures require  a  secondary  operation  for  closure,  unless 
the  wound  is  so  clean  at  the  primary  operation  as  to 
warrant  its  being  done  at  that  time. 


FRACTURES  AND  WOUNDS  OF  JOINTS       143 

Mechanical  treatment: 

Resections  of  the  tarsus  have  to  be  immobihzed  for 
a  long  time  to  prevent  deformity  by  cicatricial  and 
muscular  contraction.  The  posterior  molded  plaster 
splint  is  the  best. 

An  orthopedic  shoe  should  be  worn  and  weight 
should  not  be  put  on  the  foot  until  sensitiveness  has 
disappeared. 


INDEX 


Albee  graft  for  non  union 33 

Amputation   for   fracture   of   elbow 119 

Amputation   for   fracture  of   femur 79 

Amputation  for   fracture  of  hip 129 

Angulation,  in  fracture  of  femur 96 

Ankle,  treatment  of  fractures  of 136 

Astragalectomy,  for  fractures  of  ankle  and  tarsus 137 

Astragalectomy,  for  mal-union  of  foot  and  ankle 139 

Balkan  frame 87 

Ball  method  for  treating  fractures  of  metacarpals 72 

Ball  rifle,  fractures  usually  uninfected 11 

Ball  rifle,  lesions  produced  by 9 

Ball  shrapnel,  infection  in  fractures  caused  by     ......      .  11 

Bandage  method,  Pouliquen's 74 

Barrack  frame,  for  suspension  and  traction 41 

Bomb,  fractures  usually  infected 11 

Bone  fragments,  explosive  effect  of 8 

Bone  grafts,  ineffectual  when  nutrient  vessels  are  injured   ....  18 

Bone  grafts,  inlay 19,  33,  134 

Bone   sinuses,   operations   for 30 

Bone   sinuses,   stains    for 32 

Bone  splinters,  gradually  absorbed  when  detached 13 

Bones,  distinction  between  fractures  and  wounds  of 3 

Bones,  effects  produced  by  missiles  upon 8 

Cabot's  splint .      103,  137 

Callus,   control   of   exuberant 15 

Callus,  repair  of  fractured 33 

Callus,   flasklike      .      .      .  • .'    .  17,  '32 

Carrel  tubes  for  doubtfully  clean  wounds .      .26 

Carrel  tubes  for  drainage 28 

Clavicle  and  scapula,  treatment  of  fractures  of 61 

Codavilla   pin 76,  83,  86,  92,  98 

Coexistant  fractures  of  thigh  and  leg 90 

Delayed  primary  suture,  definition  of .  I?2 

Delayed  primary  suture,  for  fractures  by  penetration 23 

Delayed  union,  Delbet  apparatus  for 34 

Delayed  union  in  fracture  of  knee .      .  134 

Delayed  union,  injection  of  blood  for 84 

Delbet  apparatus  for  delayed  union 34 

Delbet  femur  splint,  for  ambulatory  use 96 

Delbet  femur  splint,  for  angulation         '  .      .  96 

Delbet  leg  splint,  for  ambulatory  use .  106 

Drainage  tubes   for  infected   fractures 27,  28 

Drainage  Tubes,   Carrel's 26,  28 

Elbow,  treatment  of  fractures  of 116 

Elbow,  sun  treatment  for  fractures  of 121 

Femur  (fracture  of),  advisability  of  amputation  for 79 

Femur   (fracture  of),  angulation  in 95 

145 


l4i6  INDEX 

Femur  (fracture  of),  danger  of  pulmonary  complications  subsequent 

upon ,      ,      .      .  93 

Femur  (fracture  of),  Delbet's  ambulatory  spFnt  for 97 

Femur   (fracture  of),  Hennequin's  method   for 89 

Femur  (fracture  of),  plaster  of  Paris  collar  for 92 

Femur    (fracture  of),  supplementary   sling   for   suspension  of  sound 

limb   in .      .  81 

Femur   (fracture  of),  transport  of 73 

Femur  (fracture  of),  with  coexistent  fracture  of  leg 90 

Femur   (fracture  of),  refracture  of 94 

Fibula  and  tibia,  treatment  of  fractures  of 102 

Finochietto's    stirrup 86,  99,  104 

Fixation,   internal,   bad   practice 30 

Fixation,  internal,  seldom  necessary  for  vicious  union 33 

Fixation,  internal,  unnecessary  for  non  union 33 

Foot    drop          84 

Fractures',   by   impact 24 

Fractures,  by  penetration  or  perforation 24 

Fractures,  characteristics  of  diaphyseal  and  epiphyseal 3 

Fractures,  coexistant,  of  thigh  and  leg 90 

Fractures,  definition  of 3 

Fractures,  distinction  between  wounds  of  bones  and 3 

Fractures,  double 9 

Fractures,  repair  of  infected 15 

Fractures,  radiographic  control  of 46 

Fractures,  the  essentially  war 6 

Fractures,   varieties   of 6 

Frame,  for  suspension  and  traction 36 

Frame,  for  suspension  and  traction  in  barracks 41 

Function,  harmful  effects  of  infection  upon 15 

Gaiter  method  unsuitable  for  strong  traction 104 

Gas  infection,  extension  along  muscles 27 

Glove  method,  Sinclair's 68,  71 

Glue,   Huessner's 42 

Glue,    Sinclair's 42 

Grafts,    inlay    bone 19,  33,  134 

Grenade,  fractures  usually  infected 11 

Hammock,  Sinclair's 84 

Hennequin's  method  for  fracture  of  femur 89 

Hennequin's  method   for   fracture  of  hip 128 

Heussner's  glue 42 

Hip,  treatment  of  fracture  of 126 

Hip,  treatment  of  fracture  of,  Hennequin's  method  for 128 

Humerus,  treatment  of  fracture  of 61 

Immobilization   of   fractured   wrist 124 

Infected    fractures             27 

Infection,  due  to  open  fissures 16 

Infection,  gas 27 

Infection,  harmful  effect  upon  function 15 

Infection,  in  cancellous  bone 18 

Infection  in  fractures  caused  by  different  missiles 11 

Infection,  operations  in  presence  of 27 

Infection,  synovia  not  particularly  susceptible  to 109 

Infection,  use  of  Carrel's  tubes  for 26,  28 

Inlay   graft              19,  33,  134 

Internal  fixation,  bad  practice 30 

Internal  fixation,  seldom  necessary  for  vicious  union 33 

Internal  fixation,  unnecessary  for  non-union 33 


INDEX  147 

Knee,  treatment  of  fracture   of         180 

Knee,  loose  joints  caused  by  wrongly  applied  traction 46 

Mai   union 33 

Mai  union  of  foot  and  ankle 140 

Medulla,  danger  of  small  openings  into 10 

Metacarpus  and  phalanges,  treatment  of  fractures  of 72 

Metatarsus  and  tarsus,  treatment  of  fractures  of 140 

Missiles,  effects  produced  upon  bones 8 

Nerve   lesions 46 

Non  union 33 

Oilier  incision,  for  resection  of  elbow 118 

Ollier's    periosteum    elevator 26,  28 

Operations  in  infected  cases 27 

Operations  for  sequestra  and  bone  sinuses 30 

Operations,  primary,  necessity  of  early 21 

Operations,   primary,    technique 21 

Operations,  primary,  usefulness  of  X-ray  in 22 

Osteitis  in  epiphyses  and  short  bones 18 

Osteomyelitis 16 

Periosteum  Elevator   (Oilier) 26,  28 

Phalanges,  treatment  of   fractures   of 72 

Pin,   Codavilla's 76,  83,  86,  92,  98 

Plaster  of  Paris,  collar  for  fractured  femur 92 

Plaster  of  Paris  for  fractured  wrist 124 

Plaster  of  Paris   for  resected   astragalus 139 

Plaster  of  Paris  for  transport  of  fractured  ankle 137 

Plaster  of  Paris  for  transport  of  fractured  femur 78 

Plaster  of  Paris  for  transport  of  fractured  knee 131 

Plaster  of  Paris  for  transport  of  fractured  hip 126 

Plaster  of  Paris  unsuitable  for  treatment  of  fresh  fractures   ...  36 

Plates,  stereoscopic,  for  location  of  sequestra 31 

Pouliquen's  Bandage  Method 74 

Primary  operations,  necessity  of  early 21 

Primary  operations,  technique    of 21 

Primary  operations,  usefulness  of  X-ray  in 22 

Primary  suture,  definition   of 23 

Primary  suture,  for   fractures   by   impact 24 

Primary  suture,  for  fractures  by  penetration  or  perforation   ...  24 

Primary  suture,  for   fractures   of   femur 80 

Primary  suture,  for  uncomplicated  wounds  of  soft  parts   ....  23 

Primary  suture,  in   presence   of   fractures 23 

Radius  and   ulna,  treatment  of  fractures  of 64 

Ransohoff's  tongs 77,  86,  89,  92,  98,  101 

Refracture    of    femur 94 

Repair  of  fractures,  different  iij  epiphyses  and  diaphyses       ....  18 

Repair  of  fractures,  in    extensive    comminution 12 

Repair  of  fractures,  influence   of   infection    on      .      .      .            ...  12 

Repair  of  fractures,  process  of 12 

Repair  of  fractures,  process  of  stimulated  by  mild  infection   ...  16 

Repair  of  fractures,  radiographic   control  of 46 

Resection,  general    technique    of 28 

Resection,  of  diaphyseal    fractures 28 

Resection,  of  fractured  elbow 116,  118 

Resection,  of  fractured  hip 127,  129 

Resection,  of  fractured  joints 28 

Resection,  of  fractured  knee     ...            133 

Resection,  of  fractured  tarsus  and  metatasus l40 

Resection,  of  fracture,  wrist 122 


148  INDEX 

Resection,  partial,  for  fractured  ankle 137 

Resection,  secondary 134 

Rifle  ball,  fractures  usually  uninfected 11 

Rifle  ball,  lesions  produced  by 9 

Scapula,  treatment  of  fractures  of 61 

Scar   tissue,   infiltration  of   soft   parts   by 15 

Secondary  resection 134 

Secondary  suture,  definition  of 23 

Sequestra,  contained    in    flasklike    callus 17,  32 

Sequestra,  location   of 31 

Sequestra,  operations    for 30 

Sequestra,  sinuses   reading  to 16 

Sequestra,  stereoscopic  plates  for  location  of 31 

Shell,  fractures  must  be  regarded  as  infected  ........  11 

Shell   fragments,  lesions  produced  by 9 

Shoulder,  treatment  of  fractures  of Ill 

Shrapnel  ball,  infection  in  fractures  caused  by 11 

Sinclair's  glove  method  for  fractures  of  forearm 68 

Sinclair's  glove  method  for  fractures  of  metacarpals 72 

Sinclair's  glue *2 

Sinclair's  hammock 84 

Sinclair's  skate  for  traction  in  low  fractures  of  leg 104 

Sinclair's  skate  for  use  in  presence  of  foot  wounds 106 

Sinclair's  splint  for  forearm 71 

Sinuses,   bone .  30 

Skate   method,   Sinclair's 104,  106 

Sling,   supplementary    for   suspension   of   sound   limb   in    fracture   of 

femur .  82 

Spanish   windlass  twist 53,  74 

Splints,  Cabot    leg 103,  137 

Splints,  "Caliper" 94 

Splints,  Delbet's   ambulatory   famur 96 

Splints,  Delbet's  ambulatory  leg 106 

Splints,  Delorme's    aluminium    gutter 78 

Splints,  double  gutter,   for   fractured   elbow 121 

Splints,  for  transport  of   fractured   humerus 51 

Splints,  Hodgen's 36,  81,  90,  99,  100,  103,  128,  135,  139 

Splints,  Jones'  cock-up  arm 46 

Splints,  Jones'  traction  humerus 51,  67 

Splints,  Liston 77 

Splints,  metal  cock-up,  for  drop  wrist 46 

Splints,  Murray's  modification  of  Thomas  traction  arm   .      .     51,  52,  64 

Splints,  Plaster  of  Paris,  for  hip 126,  129 

Splints,  Plaster  of  Paris,  for  knee 130,  133 

Splints,  Plaster  of  Paris,  for  wrist 124 

Splints,  Sinclair,  for  forearm 71 

Splints,  Thomas   ambulatory,  or  knee .'94 

Splints,  Thomas,  for  use  in  absence  of  portable  X-ray   .....  82 

Splints,  Thomas  half-ring  leg      .      .      . 74,  80 

Splints,  Thomas   traction   arm 52,   66,  69 

Splints,  Thomas  traction  leg     .      .      .     74,  78,  80,  100,  192,  108,  131,  135 

Splints,  Van  de  Veld '.'     .'    '70,  71 

Splints,  wire   ladder,  for  wrist .      .      .      .     '.      .  122 

Stains,  for  bone  sinuses '.      ,  82 

Stereoscopic  plates,  for  location  of  sequestra   ........  31 

Stirrup,  Finochietto's .      .     86,  99,  104 

Sun  treatment,  for  fractures  of  elbow  . 121 

Suspension  of  sound  limb,  in  fractures  of  femur 81 


INDEX  149 

Suspension  and  traction,  advantages   of 36 

Suspension  and  traction,  barracli    frame    for 41 

Suspension  and  traction,  description    of   method 36 

Suspension  and  traction,  for  fractured    astragalus      ......  139 

Suspension  and  traction,  for  fracture   of  elbow     .      .      .      .     *.      .      .118 

Suspension  and  traction,  for  fracture  of  femur 80 

Suspension  and  traction,  for  fractured   hip 128 

Suspension  and  traction,  for  fractures   of   humerus 67 

Suspension  and  traction,  for  fractures   of   knee 185 

Suspension  and  traction,  for  fractures  of  leg 103 

Suspension  and  traction,  for  fractures  of  radius  and  ulna  ....  66 

Suspension  and  traction,  frame   for 36 

Suspension  and  traction,  metohds  of  attaching  apparatus  to  limbs     .  42 

Suspension  and  traction,  trolley   bar   for 40 

Suspension  and  traction,  weights   for 41 

Suture,  delayed  primary,  definition  of 23 

Suture,  primary,  definition  of 23 

Suture,  primary,  for   fractures  by  impact 24 

Suture,  primary,  for  fractures  by  penetration  or  perforation     ...  24 

Sutue,  primary,  for   fractures  of   femur .  80 

Suture,  primary,  for  uncomplicated  wounds  of  soft  parts   ....  24 

Suture,  primary,  in  presence  of  fractures 23 

Suture,  secondary,  definition  of 23 

Synovia,  not   extremely   susceptible  to   infection 109 

Tarsus  and  metatarsus,  treatment  of  fractures  of 140 

Tibia  and  fibula,  treatment  of  fractures  of 102 

Tongs,  Ransohoff' s 77,  86,  89,  92,  98,  101 

Traction,  for  coexistent  fractures  of  thigh  and  leg 90 

Traction,  for   fracture  of   femur 84 

Traction,  methods   of   producing 43 

Transport  of  fractures 20 

Treatment  of  fractures,  ankle         136 

Treatment  of  fractures,  clavicle  and   scapula 61 

Treatment  of  fractures,  elbow .115 

Treatment  of  fractures,  femur 73 

Treatment  of  fractures,  femur,  lower  third  of 101 

Treatment  of  fractures,  femur,  middle   third    of 99 

Treatment  of  fractures,  femur,  neck    of 97 

Treatment  of  fractures,  femur,  upper    third    of 97 

Treatment  of  fractures,  hip 126 

Treatment  of  fractures,  humerus 61 

Treatment  of  fractures,  knee 130 

Treatment  of  fractures,  metacarpus  and  phalanges 72 

Treatment  of  fractures,  radir.s  and  ulna 64 

Treatment  of  fractures,  shoulder Ill 

Treatment  of  fractures,  tarsus    and    metatarsus 140 

Treatment  of  fractures,  tibia   and   fibula 102 

Treatment  of  fractures,  wrist 121 

Trolley  bar,  for  suspension  and  traction 40 

Twist,   Spanish   windlass 63,       74 

Ulna,  treatment  of  fractures  of G4 

Union,  delayed  by   infection 15 

Union,  delayed,  Delbet  apparatus  for 34 

Union,  delayed  in  fracture  of  knee 135 

Union,  delayed  injections  of  blood  for 34 

Union,  non 33 

Union,  non,  inlay  graft  for 33 

Union,  vicious        33 


150  INDEX 

Union,  vicious,  internal  fixation  unnecessary  for   ....••.  83 

Union,  vicious,  of  foot  and  ankle              ..<..<>.....  139 

Weights,  for  suspension  and  traction 41 

Windlass  twyst,  Spanish 63,  74 

Wounds  of  bones 3 

Wounds  of  joints 109 

Wrist,  treatment  of  fractures  of 121 


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